Provider Demographics
NPI:1497987333
Name:MELVIN, JACQUETTA WOODS (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JACQUETTA
Middle Name:WOODS
Last Name:MELVIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACQUETTA
Other - Middle Name:A
Other - Last Name:WOODS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2815 CATES AVE
Mailing Address - Street 2:CAMPUS BOX 7304
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27695-7304
Mailing Address - Country:US
Mailing Address - Phone:919-515-2563
Mailing Address - Fax:
Practice Address - Street 1:2815 CATES AVE
Practice Address - Street 2:CAMPUS BOX 7304
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27695-7304
Practice Address - Country:US
Practice Address - Phone:919-515-2563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01936363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC2438AMedicare UPIN