Provider Demographics
NPI:1851462097
Name:JACKSON, SHARON M (LCSW)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:M
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 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE. 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:573-860-6000
Mailing Address - Fax:573-860-6016
Practice Address - Street 1:965 MATTOX DR
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-2365
Practice Address - Country:US
Practice Address - Phone:673-860-6000
Practice Address - Fax:573-860-6016
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0056421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000078508Medicare ID - Type Unspecified