Healthcare Provider Details

I. General information

NPI: 1598426884
Provider Name (Legal Business Name): RUSSELL NEILEND JACKSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2022
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 E BROADWAY STE 201A
COLUMBIA MO
65201-4489
US

IV. Provider business mailing address

PO BOX 843966
KANSAS CITY MO
64184-3966
US

V. Phone/Fax

Practice location:
  • Phone: 515-460-0047
  • Fax:
Mailing address:
  • Phone: 573-884-3300
  • Fax: 573-884-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number2021011992
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2021011992
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number2021011992
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: