Provider Demographics
NPI:1083973697
Name:JACKSON, MONIQUE LASEAN (MA)
Entity Type:Individual
Prefix:MRS
First Name:MONIQUE
Middle Name:LASEAN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 BUFORD DR
Mailing Address - Street 2:APT# 702
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-5109
Mailing Address - Country:US
Mailing Address - Phone:678-523-1627
Mailing Address - Fax:678-765-0300
Practice Address - Street 1:2910 BUFORD DR
Practice Address - Street 2:APT# 702
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-5109
Practice Address - Country:US
Practice Address - Phone:678-523-1627
Practice Address - Fax:678-765-0300
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator