Provider Demographics
NPI:1568290237
Name:JACKSON, MONICA HICKS
Entity type:Individual
Prefix:MRS
First Name:MONICA
Middle Name:HICKS
Last Name:JACKSON
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 1:411 W LAKE LANSING RD STE C125
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-8485
Mailing Address - Country:US
Mailing Address - Phone:517-574-4192
Mailing Address - Fax:
Practice Address - Street 1:411 W LAKE LANSING RD STE C125
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8485
Practice Address - Country:US
Practice Address - Phone:517-574-4192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-24
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISC0000001114637101YS0200X
MI6451022433101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool