Healthcare Provider Details

I. General information

NPI: 1134858392
Provider Name (Legal Business Name): SARAH MARIE JACKSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2022
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 WINDING WOODS DR STE 120
O FALLON MO
63366-4772
US

IV. Provider business mailing address

PO BOX 776084
CHICAGO IL
60677-6084
US

V. Phone/Fax

Practice location:
  • Phone: 636-614-3280
  • Fax: 636-272-3680
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2025040108
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: