Provider Demographics
NPI:1568204915
Name:JACKSON-GREEN, KEOSHIA MONIQUE
Entity type:Individual
Prefix:
First Name:KEOSHIA
Middle Name:MONIQUE
Last Name:JACKSON-GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58608 BELLEVIEW RD STE B
Mailing Address - Street 2:
Mailing Address - City:PLAQUEMINE
Mailing Address - State:LA
Mailing Address - Zip Code:70764-3915
Mailing Address - Country:US
Mailing Address - Phone:504-475-4388
Mailing Address - Fax:
Practice Address - Street 1:58608 BELLEVIEW RD STE B
Practice Address - Street 2:
Practice Address - City:PLAQUEMINE
Practice Address - State:LA
Practice Address - Zip Code:70764-3915
Practice Address - Country:US
Practice Address - Phone:504-475-4388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-07
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)