Provider Demographics
NPI:1891178281
Name:JACKSON, MONIQUE (OD)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 CANAL ST
Mailing Address - Street 2:STE B
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-5942
Mailing Address - Country:US
Mailing Address - Phone:985-966-5029
Mailing Address - Fax:504-777-7790
Practice Address - Street 1:4205 CANAL ST
Practice Address - Street 2:STE B
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-5942
Practice Address - Country:US
Practice Address - Phone:504-777-7780
Practice Address - Fax:504-777-7790
Is Sole Proprietor?:No
Enumeration Date:2015-07-02
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1797-731AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist