Healthcare Provider Details

I. General information

NPI: 1255264438
Provider Name (Legal Business Name): MONIQUE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3590B PELHAM PKWY # 154
PELHAM AL
35124-2034
US

IV. Provider business mailing address

3590B PELHAM PKWY # 154
PELHAM AL
35124-2034
US

V. Phone/Fax

Practice location:
  • Phone: 205-534-9624
  • Fax:
Mailing address:
  • Phone: 205-534-9624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: