Provider Demographics
NPI:1326588575
Name:JACKSON, MONISA
Entity Type:Individual
Prefix:
First Name:MONISA
Middle Name:
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 1:6748 YELLOWHAMMER PL
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-2694
Mailing Address - Country:US
Mailing Address - Phone:775-357-2623
Mailing Address - Fax:
Practice Address - Street 1:1325 AIRMOTIVE WAY
Practice Address - Street 2:SUITE 9
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-3201
Practice Address - Country:US
Practice Address - Phone:775-357-2623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1405249095Medicaid