Provider Demographics
NPI:1225672371
Name:DAVIS-JACKSON, SALLY ANN (MSW, PLMHP, CSW)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:ANN
Last Name:DAVIS-JACKSON
Suffix:
Gender:F
Credentials:MSW, PLMHP, CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26
Mailing Address - Street 2:
Mailing Address - City:BASSETT
Mailing Address - State:NE
Mailing Address - Zip Code:68714-0026
Mailing Address - Country:US
Mailing Address - Phone:402-684-2908
Mailing Address - Fax:402-913-3454
Practice Address - Street 1:202 E HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:BASSETT
Practice Address - State:NE
Practice Address - Zip Code:68714-6052
Practice Address - Country:US
Practice Address - Phone:402-684-2908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE120031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty