Provider Demographics
NPI:1447261110
Name:JACKSON, MICHELLE RENE' (MSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:RENE'
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24728 FALCON ROAD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-6137
Mailing Address - Country:US
Mailing Address - Phone:417-622-8472
Mailing Address - Fax:
Practice Address - Street 1:24728 FALCON RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-6137
Practice Address - Country:US
Practice Address - Phone:417-622-8472
Practice Address - Fax:417-588-4296
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050184821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical