Provider Demographics
NPI:1770749905
Name:JACKSON, ALFAYE (PLPC)
Entity type:Individual
Prefix:MS
First Name:ALFAYE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 FOX CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-3620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:104 FOX CREEK RD
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3620
Practice Address - Country:US
Practice Address - Phone:417-693-2770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-07
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008015070101YP2500X
MO2015044726101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490047336Medicaid