Provider Demographics
NPI:1730847534
Name:JACKSON, JAY BRIAN (LCSW)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:BRIAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13722 JEFFERSON RD
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65074-2006
Mailing Address - Country:US
Mailing Address - Phone:573-338-2861
Mailing Address - Fax:
Practice Address - Street 1:13722 JEFFERSON RD
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:MO
Practice Address - Zip Code:65074-2006
Practice Address - Country:US
Practice Address - Phone:573-782-0145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20020319921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical