Provider Demographics
NPI:1427594092
Name:JACKSON, MONIQUE (LGSW)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9701 PHILADELPHIA CT STE R
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-4435
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9701 PHILADELPHIA CT STE R
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-4435
Practice Address - Country:US
Practice Address - Phone:301-477-3339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-06
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22165104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker