Provider Demographics
NPI:1225673445
Name:JACKSON, MELINDA LOUISE (CRNP)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:LOUISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:LOUISE
Other - Last Name:ZUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:400 TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-3511
Mailing Address - Country:US
Mailing Address - Phone:205-335-7683
Mailing Address - Fax:
Practice Address - Street 1:400 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3511
Practice Address - Country:US
Practice Address - Phone:205-335-7683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-12
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-117801163W00000X, 363LN0005X, 363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA