MEDICARE: KELLY FAYE 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	2015020177	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	133585346	OTHER	MO	CAQH
2	2015020177	OTHER	MO	LCSW LICENSE NUMBER

General Provider Information

NPI Number	:	1598180630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY FAYE JACKSON LCSW

Provider Business Mailing Address
First Line	:	3007 DAHLIA DR
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65202-3862
Country	:	US
Telephone Number	:	660-238-3154
Fax Number	:	573-442-7505

Provider Business Practice Location Address
First Line	:	409 VANDIVER DR
Second Line	:	BUILDING 4, SUITE 102
City	:	COLUMBIA
State	:	MO
Zip	:	65202-3754
Country	:	US
Telephone Number	:	573-289-0792
Fax Number	:	573-442-7505

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

Provider Enumeration Date	:	02/26/2014
Last Update Date	:	11/30/2016

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