Provider Demographics
NPI:1427562156
Name:JACKSON, MELISSA B (FNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:B
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 54024
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39288-4024
Mailing Address - Country:US
Mailing Address - Phone:601-624-6552
Mailing Address - Fax:
Practice Address - Street 1:129 FOUNTAINS BLVD STE 101
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6344
Practice Address - Country:US
Practice Address - Phone:769-300-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902231363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily