Provider Demographics
NPI:1114579208
Name:JACKSON, MONIQUE (LLPC)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31600 SCHOENHERR RD APT 12
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-1919
Mailing Address - Country:US
Mailing Address - Phone:313-721-7474
Mailing Address - Fax:
Practice Address - Street 1:4410 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6515
Practice Address - Country:US
Practice Address - Phone:248-554-6414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017459101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor