Provider Demographics
NPI:1932564275
Name:JACKSON, SIERRA C (LMSW, MPA)
Entity Type:Individual
Prefix:MS
First Name:SIERRA
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMSW, MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1042 NEW JERSEY ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-3048
Mailing Address - Country:US
Mailing Address - Phone:785-330-3166
Mailing Address - Fax:
Practice Address - Street 1:221 W MAIN ST
Practice Address - Street 2:
Practice Address - City:COUNCIL GROVE
Practice Address - State:KS
Practice Address - Zip Code:66846-1704
Practice Address - Country:US
Practice Address - Phone:785-330-3166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS7787104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker