Provider Demographics
NPI:1255882841
Name:JACKSON, MONICA
Entity type:Individual
Prefix:
First Name:MONICA
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 1:134 SE 5TH AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4095
Mailing Address - Country:US
Mailing Address - Phone:971-777-0756
Mailing Address - Fax:503-648-5269
Practice Address - Street 1:134 SE 5TH AVE
Practice Address - Street 2:SUITE C
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4095
Practice Address - Country:US
Practice Address - Phone:971-777-0756
Practice Address - Fax:503-648-5269
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278095Medicaid