Healthcare Provider Details

I. General information

NPI: 1861743916
Provider Name (Legal Business Name): MONIQUE JARDEL JAMISON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2012
Last Update Date: 09/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6004 BUIST AVE FL 2
PHILADELPHIA PA
19142-3503
US

IV. Provider business mailing address

6004 BUIST AVE FL 2
PHILADELPHIA PA
19142-3503
US

V. Phone/Fax

Practice location:
  • Phone: 267-602-9789
  • Fax:
Mailing address:
  • Phone: 267-602-9789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: