Provider Demographics
NPI:1407914328
Name:JACKSON, AMY MICHELLE (MSW, LCSW, ACSW)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MICHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW, LCSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 WEST BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:MO
Mailing Address - Zip Code:65236
Mailing Address - Country:US
Mailing Address - Phone:660-634-2380
Mailing Address - Fax:660-376-3204
Practice Address - Street 1:225 W HAYDEN ST
Practice Address - Street 2:SUITE 210
Practice Address - City:MARCELINE
Practice Address - State:MO
Practice Address - Zip Code:64658-1049
Practice Address - Country:US
Practice Address - Phone:660-376-3200
Practice Address - Fax:660-376-3204
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030240171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical