Healthcare Provider Details

I. General information

NPI: 1730847534
Provider Name (Legal Business Name): JAY BRIAN JACKSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2021
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13722 JEFFERSON RD
RUSSELLVILLE MO
65074-2006
US

IV. Provider business mailing address

13722 JEFFERSON RD
RUSSELLVILLE MO
65074-2006
US

V. Phone/Fax

Practice location:
  • Phone: 573-782-0145
  • Fax:
Mailing address:
  • Phone: 573-338-2861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2002031992
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: