Healthcare Provider Details

I. General information

NPI: 1922955459
Provider Name (Legal Business Name): KEISHA JACKSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2026
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 RIVERINE DR APT 907
SAINT CHARLES MO
63303-4298
US

IV. Provider business mailing address

9 RIVERINE DR APT 907
SAINT CHARLES MO
63303-4298
US

V. Phone/Fax

Practice location:
  • Phone: 314-685-0061
  • Fax:
Mailing address:
  • Phone: 314-685-0061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2025048875
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: