Provider Demographics
NPI:1699703579
Name:JACKSON, SETH N (MSW)
Entity type:Individual
Prefix:
First Name:SETH
Middle Name:N
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 S ASH ST
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-3222
Mailing Address - Country:US
Mailing Address - Phone:417-667-8352
Mailing Address - Fax:417-667-9216
Practice Address - Street 1:815 S ASH ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-3222
Practice Address - Country:US
Practice Address - Phone:417-667-8352
Practice Address - Fax:417-667-9216
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050349691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical