Provider Demographics
NPI:1467525865
Name:MELTON, JASON G (CFNP)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:G
Last Name:MELTON
Suffix:
Gender:M
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9075 SANDIDGE CENTER CV
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-3514
Mailing Address - Country:US
Mailing Address - Phone:662-895-4949
Mailing Address - Fax:662-895-6776
Practice Address - Street 1:9075 SANDIDGE CENTER CV
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-3514
Practice Address - Country:US
Practice Address - Phone:662-895-4949
Practice Address - Fax:662-895-6776
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR867427363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q74469Medicare UPIN
MS500002276Medicare ID - Type Unspecified