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General NPI Number Information
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NPI Number | 1659670735
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Entity Type | Organization
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Legal Business Name | MARSHALL JACKSON GROUP LLC
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Dates
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Enumeration Date | 03/15/2011
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Last Update Date | 03/15/2011
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Provider Practice Location Address
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Address Line | 1606 S BIG BEND BLVD
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City | SAINT LOUIS
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State | MO
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Zip | 63117-2208
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Country | US
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Telephone | 314-645-1076
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Fax | 314-645-5135
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Provider Business Mailing Address
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Address Line | 1606 S BIG BEND BLVD
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City | SAINT LOUIS
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State | MO
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Zip | 63117-2208
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Country | US
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Telephone | 314-645-1076
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Fax | 314-645-5135
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Authorized Official
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Title or Position | OWNER
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Name | MS. MICHELE MARSHALL-MOORE
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Credential | MSW
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Telephone | 314-645-1075
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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 | 002365
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License Number State | MO
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