Healthcare Provider Details

I. General information

NPI: 1568204915
Provider Name (Legal Business Name): KEOSHIA MONIQUE JACKSON-GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2024
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58608 BELLEVIEW RD STE B
PLAQUEMINE LA
70764-3915
US

IV. Provider business mailing address

58608 BELLEVIEW RD STE B
PLAQUEMINE LA
70764-3915
US

V. Phone/Fax

Practice location:
  • Phone: 504-475-4388
  • Fax:
Mailing address:
  • Phone: 504-475-4388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code347B00000X
TaxonomyBus
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number007370753
License Number StateLA
# 7
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: