Individual
KELLY FAYE JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LCSW
Contact information
Practice address
409 VANDIVER DR, BUILDING 4, SUITE 102, COLUMBIA, MO 65202-3754
(573) 289-0792
(573) 442-7505
Mailing address
3007 DAHLIA DR, COLUMBIA, MO 65202-3862
(660) 238-3154
(573) 442-7505
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
2015020177
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
133585346
CAQH
MO
01
—
2015020177
LCSW LICENSE NUMBER
MO
Enumeration date
02/26/2014
Last updated
11/30/2016
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