Provider Demographics
NPI:1144526369
Name:JACKSON, SHALONDA MONIQUE
Entity type:Individual
Prefix:MISS
First Name:SHALONDA
Middle Name:MONIQUE
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 1:5304 DAYWOOD ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-7917
Mailing Address - Country:US
Mailing Address - Phone:702-649-5995
Mailing Address - Fax:702-399-9801
Practice Address - Street 1:5304 DAYWOOD ST
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-7917
Practice Address - Country:US
Practice Address - Phone:702-649-5995
Practice Address - Fax:702-399-9801
Is Sole Proprietor?:No
Enumeration Date:2011-02-04
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral