Provider Demographics
NPI:1114673381
Name:JACKSON, MELISSA (LAC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 JACK MARTIN BLVD # E2
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-7772
Mailing Address - Country:US
Mailing Address - Phone:732-239-3427
Mailing Address - Fax:
Practice Address - Street 1:220 JACK MARTIN BLVD # E2
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-7772
Practice Address - Country:US
Practice Address - Phone:732-920-3434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-26
Last Update Date:2022-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00133700101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health