Provider Demographics
NPI:1013228600
Name:JACKSON, MELANIE J (MS, LMHC, NCC)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, LMHC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5840 RED BUG LAKE RD
Mailing Address - Street 2:#1548
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-5011
Mailing Address - Country:US
Mailing Address - Phone:423-342-6422
Mailing Address - Fax:407-695-8803
Practice Address - Street 1:5840 RED BUG LAKE RD
Practice Address - Street 2:#1548
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-5011
Practice Address - Country:US
Practice Address - Phone:423-342-6422
Practice Address - Fax:407-695-8803
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 3045101YM0800X, 101YM0800X
NCNCC 33945101Y00000X
TX18548101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional