Provider Demographics
NPI:1235808551
Name:JACKSON, MELISSA EILEEN (LPT)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:EILEEN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71175 AURORA RD
Mailing Address - Street 2:
Mailing Address - City:DESERT HOT SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92241-7631
Mailing Address - Country:US
Mailing Address - Phone:760-251-8858
Mailing Address - Fax:760-329-8889
Practice Address - Street 1:71175 AURORA RD
Practice Address - Street 2:
Practice Address - City:DESERT HOT SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92241-7631
Practice Address - Country:US
Practice Address - Phone:760-251-8858
Practice Address - Fax:760-329-8889
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-09
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABVNPT225C00000X
CA35652167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor