Provider Demographics
NPI:1497127419
Name:JACKSON-ROBERTS, STACEY (LCSW-C)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:
Last Name:JACKSON-ROBERTS
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 S 300 W UNIT S325
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-2528
Mailing Address - Country:US
Mailing Address - Phone:424-320-0929
Mailing Address - Fax:
Practice Address - Street 1:570 S 300 W UNIT S325
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-2528
Practice Address - Country:US
Practice Address - Phone:424-320-0929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-29
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD194641041C0700X
UT12464906-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical