Provider Demographics
NPI:1275742025
Name:JACKSON, ROSE MARIE (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ROSE
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:MS
Other - First Name:ROSE
Other - Middle Name:MARIE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3150 PARKER RD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-3760
Mailing Address - Country:US
Mailing Address - Phone:314-921-4603
Mailing Address - Fax:314-921-4603
Practice Address - Street 1:3150 PARKER RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-3760
Practice Address - Country:US
Practice Address - Phone:314-921-4603
Practice Address - Fax:314-921-4603
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0029921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical