Healthcare Provider Details

I. General information

NPI: 1821307547
Provider Name (Legal Business Name): DAVAUGHN Y JACKSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2010
Last Update Date: 09/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 S BROADWAY
SAINT LOUIS MO
63118-4608
US

IV. Provider business mailing address

900 E LAHARPE ST
KIRKSVILLE MO
63501-4520
US

V. Phone/Fax

Practice location:
  • Phone: 314-772-2205
  • Fax: 314-772-9264
Mailing address:
  • Phone: 660-665-1962
  • Fax: 660-665-3989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2009022179
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: