Provider Demographics
NPI:1942499272
Name:JACKMAN, MONICA MOORE (OTD, MHS, OTR/L)
Entity Type:Individual
Prefix:DR
First Name:MONICA
Middle Name:MOORE
Last Name:JACKMAN
Suffix:
Gender:F
Credentials:OTD, MHS, OTR/L
Other - Prefix:DR
Other - First Name:MONICA
Other - Middle Name:MOORE
Other - Last Name:JACKMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTD, MHS, OTR/L
Mailing Address - Street 1:3242 SW FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-3480
Mailing Address - Country:US
Mailing Address - Phone:352-283-2484
Mailing Address - Fax:
Practice Address - Street 1:600 SW DARWIN BLVD
Practice Address - Street 2:SUITE 101B
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-3365
Practice Address - Country:US
Practice Address - Phone:772-905-8761
Practice Address - Fax:772-905-8782
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT9381225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics