Provider Demographics
NPI:1952338543
Name:JACKSON, MONIQUE RACHELLE (CFNP)
Entity Type:Individual
Prefix:MISS
First Name:MONIQUE
Middle Name:RACHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 W. WASHINGTON BLVD.
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015
Mailing Address - Country:US
Mailing Address - Phone:213-623-2225
Mailing Address - Fax:213-861-5825
Practice Address - Street 1:1120 W. WASHINGTON BLVD.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015
Practice Address - Country:US
Practice Address - Phone:213-623-2225
Practice Address - Fax:213-861-5825
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8338363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP0083380Medicaid