Provider Demographics
NPI:1437622677
Name:JACKSON, MONEE
Entity Type:Individual
Prefix:
First Name:MONEE
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 1:412 ANDORRA GLEN CT
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19444-2524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 OLD YORK ROAD
Practice Address - Street 2:SUITE 400
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-1904
Practice Address - Country:US
Practice Address - Phone:877-504-3626
Practice Address - Fax:610-675-2604
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty