Provider Demographics
NPI:1730457300
Name:REA, JACINDA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JACINDA
Middle Name:
Last Name:REA
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:PO BOX 600
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:MO
Mailing Address - Zip Code:64759-0600
Mailing Address - Country:US
Mailing Address - Phone:417-214-6648
Mailing Address - Fax:
Practice Address - Street 1:203 W 11TH ST
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:MO
Practice Address - Zip Code:64759-1426
Practice Address - Country:US
Practice Address - Phone:417-214-6648
Practice Address - Fax:417-944-1440
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-09
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20160294851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO4277661OtherAETNA
MO002628535OtherCTS CHILDRENS TREATMENT SERVICES
MOD27240OtherHEALTHLINK
MO1730457300Medicaid
MO601117207OtherMAGELLAN
MO1280287OtherMO CARE
MOMA6351Medicare PIN