Healthcare Provider Details

I. General information

NPI: 1447261110
Provider Name (Legal Business Name): MICHELLE RENE' JACKSON MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3270 E HIGHWAY 54
EL DORADO SPRINGS MO
64744-8201
US

IV. Provider business mailing address

3270 E HIGHWAY 54
EL DORADO SPRINGS MO
64744-8201
US

V. Phone/Fax

Practice location:
  • Phone: 417-296-2705
  • Fax:
Mailing address:
  • Phone: 417-296-2705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2024044142
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: