Provider Demographics
NPI:1205367737
Name:JACKSON, MELISSA GRACE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:GRACE
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 1:1601 W BALBOA BLVD
Mailing Address - Street 2:APT D
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4527
Mailing Address - Country:US
Mailing Address - Phone:949-723-2388
Mailing Address - Fax:
Practice Address - Street 1:1601 W BALBOA BLVD
Practice Address - Street 2:APT D
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4527
Practice Address - Country:US
Practice Address - Phone:949-723-2388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-26
Last Update Date:2017-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor