Provider Demographics
NPI:1780055913
Name:JACKSON, MONTIGUS (MS)
Entity type:Individual
Prefix:
First Name:MONTIGUS
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 CHRISTINA DR
Mailing Address - Street 2:APT 204
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33414-2176
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:560 CHRISTINA DR
Practice Address - Street 2:APT 204
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33414-2176
Practice Address - Country:US
Practice Address - Phone:561-420-5403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 13018101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health