Healthcare Provider Details

I. General information

NPI: 1881954071
Provider Name (Legal Business Name): MS. LAKESHIA MICHELLE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 05/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 BLUE BELL TER
KEARNEY MO
64060-7313
US

IV. Provider business mailing address

2205 BLUE BELL TER
KEARNEY MO
64060-7313
US

V. Phone/Fax

Practice location:
  • Phone: 816-588-1343
  • Fax:
Mailing address:
  • Phone: 816-903-0103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: