Provider Demographics
NPI:1619412368
Name:JACKSON, MATTIE-KAY (LSCSW)
Entity type:Individual
Prefix:
First Name:MATTIE-KAY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 COLLEGE AVE STE A213
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-2781
Mailing Address - Country:US
Mailing Address - Phone:785-775-0221
Mailing Address - Fax:
Practice Address - Street 1:1133 COLLEGE AVE
Practice Address - Street 2:BUILDING A, SUITE A213
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502
Practice Address - Country:US
Practice Address - Phone:785-775-0221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-04
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS064491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical