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NPI Code Detail

MEDICARE: MONICA D JACKSON PA

MEDICARE: MONICA D JACKSON PA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant005585GA
2363A00000XPhysician AssistantPA9113041FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1548583719
Entity Type Code : Individual
Provider Name (Legal Business Name) : MONICA D JACKSON PA
Provider Business Mailing Address
First Line : PO BOX 1137
Second Line :
City : MELBOURNE
State : FL
Zip : 32902-1137
Country : US
Telephone Number : 321-952-9696
Fax Number :
Provider Business Practice Location Address
First Line : 5270 BABCOCK ST NE STE 1
Second Line :
City : PALM BAY
State : FL
Zip : 32905-4616
Country : US
Telephone Number : 321-722-5959
Fax Number : 321-722-5960
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/02/2010
Last Update Date : 04/25/2022

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Directions to “ MONICA D JACKSON PA” Practice Location

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