Provider Demographics
NPI:1518729680
Name:JACKSON, MONICA V (FS)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:V
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 MICHIGAN AVE APT A
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-5415
Mailing Address - Country:US
Mailing Address - Phone:334-739-7739
Mailing Address - Fax:
Practice Address - Street 1:1186 TREE SWALLOW DR
Practice Address - Street 2:
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-2826
Practice Address - Country:US
Practice Address - Phone:321-765-7779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFS887678246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other