Healthcare Provider Details

I. General information

NPI: 1952338543
Provider Name (Legal Business Name): MONIQUE RACHELLE JACKSON CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 06/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 W. WASHINGTON BLVD.
LOS ANGELES CA
90015
US

IV. Provider business mailing address

1120 W. WASHINGTON BLVD.
LOS ANGELES CA
90015
US

V. Phone/Fax

Practice location:
  • Phone: 213-623-2225
  • Fax: 213-861-5825
Mailing address:
  • Phone: 213-623-2225
  • Fax: 213-861-5825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8338
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: