Provider Demographics
NPI:1598180630
Name:JACKSON, KELLY FAYE (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:FAYE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3007 DAHLIA DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-3862
Mailing Address - Country:US
Mailing Address - Phone:660-238-3154
Mailing Address - Fax:573-442-7505
Practice Address - Street 1:409 VANDIVER DR
Practice Address - Street 2:BUILDING 4, SUITE 102
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65202-3754
Practice Address - Country:US
Practice Address - Phone:573-289-0792
Practice Address - Fax:573-442-7505
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-26
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20150201771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO133585346OtherCAQH
MO2015020177OtherLCSW LICENSE NUMBER