Healthcare Provider Details

I. General information

NPI: 1699703579
Provider Name (Legal Business Name): SETH N JACKSON MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 S ASH ST
NEVADA MO
64772-3222
US

IV. Provider business mailing address

815 S ASH ST
NEVADA MO
64772-3222
US

V. Phone/Fax

Practice location:
  • Phone: 417-667-8352
  • Fax: 417-667-9216
Mailing address:
  • Phone: 417-667-8352
  • Fax: 417-667-9216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2005034969
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: