Provider Demographics
NPI:1467965095
Name:JACCOM, MELISSA PEI-LIH (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:PEI-LIH
Last Name:JACCOM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10106 67TH DR APT 6B
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-2774
Mailing Address - Country:US
Mailing Address - Phone:973-580-3877
Mailing Address - Fax:
Practice Address - Street 1:333 EARLE OVINGTON BLVD
Practice Address - Street 2:
Practice Address - City:UNIONDALE
Practice Address - State:NY
Practice Address - Zip Code:11553-3610
Practice Address - Country:US
Practice Address - Phone:516-222-8881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021449207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine