Healthcare Provider Details

I. General information

NPI: 1912522442
Provider Name (Legal Business Name): MONICA JEAN JACKSON CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 E MEMORIAL DR
POMEROY OH
45769-9569
US

IV. Provider business mailing address

90 JACKSON PIKE
GALLIPOLIS OH
45631-1562
US

V. Phone/Fax

Practice location:
  • Phone: 855-446-5937
  • Fax:
Mailing address:
  • Phone: 740-446-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number106415
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0027497
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: