Provider Demographics
NPI:1437730785
Name:JACKSON, MELISSA R (LMSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 S WAVERLY ST APT 1A
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-0801
Mailing Address - Country:US
Mailing Address - Phone:914-619-7791
Mailing Address - Fax:
Practice Address - Street 1:860 MELROSE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-4443
Practice Address - Country:US
Practice Address - Phone:914-619-7791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00000Medicaid