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General NPI Number Information
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NPI Number | 1447261110
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Entity Type | Individual
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Provider Name | MICHELLE RENE' JACKSON MSW, LCSW
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Gender | Female
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Dates
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Enumeration Date | 08/10/2006
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Last Update Date | 07/23/2015
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Provider Practice Location Address
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Address Line | 24728 FALCON RD
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City | LEBANON
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State | MO
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Zip | 65536-6137
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Country | US
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Telephone | 417-622-8472
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Fax | 417-588-4296
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Provider Business Mailing Address
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Address Line | 24728 FALCON ROAD
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City | LEBANON
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State | MO
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Zip | 65536-6137
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Country | US
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Telephone | 417-622-8472
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 2005018482
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License Number State | MO
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