Basic Information
| Provider Information | |||||||||
| NPI: | 1548583719 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | D | ||||||||
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| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1137 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329021137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3219529696 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5270 BABCOCK ST NE STE 1 | ||||||||
| Address2: | |||||||||
| City: | PALM BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329054616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217225959 | ||||||||
| FaxNumber: | 3217225960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2010 | ||||||||
| LastUpdateDate: | 04/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 005585 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA9113041 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 105825900 | 05 | FL | MEDICAID |