Basic Information
| Provider Information | |||||||||
| NPI: | 1598078297 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | N. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2797 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681032797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023544230 | ||||||||
| FaxNumber: | 4023546171 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 N 190TH PLZ | ||||||||
| Address2: | |||||||||
| City: | ELKHORN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680223974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4028156428 | ||||||||
| FaxNumber: | 4028151565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2010 | ||||||||
| LastUpdateDate: | 12/13/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 59897 | NE | N | Nursing Service Providers | Registered Nurse | 363LN0005X | 111164 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 10025866100 | 05 | NE | MEDICAID | 1598078297 | 05 | IA | MEDICAID | 111164 | 01 | NE | APRN MEDICAL LICENSE | OTHER |