Provider Demographics
NPI:1922160720
Name:JACKSON, DIANE RENE (LMSW-ACP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:RENE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMSW-ACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 HIGHTOWER PLACE DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7069
Mailing Address - Country:US
Mailing Address - Phone:618-628-0886
Mailing Address - Fax:
Practice Address - Street 1:1129 HIGHTOWER PLACE DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-7069
Practice Address - Country:US
Practice Address - Phone:618-628-0886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX313561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical