Provider Demographics
NPI:1801610860
Name:JACKMAN, MONIQUE MARIE
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:MARIE
Last Name:JACKMAN
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 1:121 W 4300 N
Mailing Address - Street 2:
Mailing Address - City:PLEASANT VIEW
Mailing Address - State:UT
Mailing Address - Zip Code:84414-1123
Mailing Address - Country:US
Mailing Address - Phone:801-336-8910
Mailing Address - Fax:
Practice Address - Street 1:5648 S 500 E
Practice Address - Street 2:
Practice Address - City:WASHINGTON TERRACE
Practice Address - State:UT
Practice Address - Zip Code:84405-7230
Practice Address - Country:US
Practice Address - Phone:804-475-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-14
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4744927-4003225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist