Kelly Faye Jackson, LCSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

2015020177 Issued in MO

Practice address

409 Vandiver Dr
Building 4, Suite 102
Columbia, MO 65202-3754

Phone

(573) 289-0792

Fax

(573) 442-7505

NPI assigned

Feb 26, 2014

Last updated

Nov 30, 2016By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1393372800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1480464000000",
    "number": "1598180630",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3007 DAHLIA DR",
            "city": "COLUMBIA",
            "state": "MO",
            "postal_code": "652023862",
            "telephone_number": "660-238-3154",
            "fax_number": "573-442-7505"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "409 VANDIVER DR",
            "address_2": "BUILDING 4, SUITE 102",
            "city": "COLUMBIA",
            "state": "MO",
            "postal_code": "652023754",
            "telephone_number": "573-289-0792",
            "fax_number": "573-442-7505"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "KELLY",
        "middle_name": "FAYE",
        "credential": "LCSW",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2014-02-26",
        "last_updated": "2016-11-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MO",
            "license": "2015020177",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CAQH",
            "identifier": "133585346",
            "state": "MO"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LCSW LICENSE NUMBER",
            "identifier": "2015020177",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Alexandria Jackson
• Christopher Duane Jackson, M.D.
• Garrett Jackson, MD
• Hunter Jackson
• Jesse Jose Jackson
• Keviana Y Jackson, MSW, LMSW
• Kimberly Jackson, RN
• Russell Neilend Jackson, PHD
• Markya Jordaine Jaco
• Cynthia Marie Kuhn Jacob, M.S., CCC-SLP

• Clinical Social Worker in Columbia, MO
• Providers in Columbia, MO by specialty
• Clinical Social Worker in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 30, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.