Provider Demographics
NPI:1215281878
Name:JACKSON, MONICA L (LPN)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5148 VALLEY FORGE DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43613-2837
Mailing Address - Country:US
Mailing Address - Phone:716-381-3824
Mailing Address - Fax:
Practice Address - Street 1:5148 VALLEY FORGE DR
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43613-2837
Practice Address - Country:US
Practice Address - Phone:716-381-3824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH151022164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH151022OtherOHIO BOARD OF NURSING