MEDICARE: GINA LYNN JACKSON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	2025042242	MO

General Provider Information

NPI Number	:	1093680605
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA LYNN JACKSON LCSW

Provider Business Mailing Address
First Line	:	6542 NASHVILLE AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63139-3427
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6542 NASHVILLE AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63139-3427
Country	:	US
Telephone Number	:	314-884-8034
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2025
Last Update Date	:	10/06/2025

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