Provider Demographics
NPI:1164990826
Name:JACKSON, BRIANNA MO'NIQUE
Entity Type:Individual
Prefix:MISS
First Name:BRIANNA
Middle Name:MO'NIQUE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 EVANGELINE ST APT 118
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3803
Mailing Address - Country:US
Mailing Address - Phone:408-966-4504
Mailing Address - Fax:
Practice Address - Street 1:1610 JACKSON ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-2030
Practice Address - Country:US
Practice Address - Phone:408-966-4504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-10
Last Update Date:2018-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst