Provider Demographics
NPI:1154064913
Name:JACKMAN, MELINA
Entity Type:Individual
Prefix:
First Name:MELINA
Middle Name:
Last Name:JACKMAN
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 1:1501 OLD BLACK HORSE PIKE APT L4
Mailing Address - Street 2:
Mailing Address - City:BLACKWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-4932
Mailing Address - Country:US
Mailing Address - Phone:856-534-1297
Mailing Address - Fax:
Practice Address - Street 1:100 TOWNSEND AVE
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:NJ
Practice Address - Zip Code:08009-9011
Practice Address - Country:US
Practice Address - Phone:609-534-9196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker