Provider Demographics
NPI:1588843684
Name:SHARP, JACKIE ANN (LISW)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:ANN
Last Name:SHARP
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 N HAYNES AVE
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52544-1133
Mailing Address - Country:US
Mailing Address - Phone:641-437-1051
Mailing Address - Fax:641-437-1404
Practice Address - Street 1:1111 N HAYNES AVE
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:IA
Practice Address - Zip Code:52544-1133
Practice Address - Country:US
Practice Address - Phone:641-437-1051
Practice Address - Fax:641-437-1404
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA057521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical