Provider Demographics
NPI:1023784782
Name:JACKSON, SHONTA MONIQUE
Entity type:Individual
Prefix:
First Name:SHONTA
Middle Name:MONIQUE
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 1:3219 HOPETOWN WAY
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-0668
Mailing Address - Country:US
Mailing Address - Phone:205-276-7365
Mailing Address - Fax:
Practice Address - Street 1:527 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130-2833
Practice Address - Country:US
Practice Address - Phone:615-564-4984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN374700000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No374700000XNursing Service Related ProvidersTechnician