Provider Demographics
NPI:1528224219
Name:JACKSON, MELISSA (MD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3250 NE 1ST AVE
Mailing Address - Street 2:SUITE 317
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33137-4191
Mailing Address - Country:US
Mailing Address - Phone:305-433-2724
Mailing Address - Fax:305-720-2110
Practice Address - Street 1:3250 NE 1ST AVE
Practice Address - Street 2:SUITE 317
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33137-4191
Practice Address - Country:US
Practice Address - Phone:305-433-2724
Practice Address - Fax:305-720-2110
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2021-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1250515132084P0800X
FLME1096212084P0800X
CAA1083582084P0804X
FLME 1096212084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGB774YMedicare PIN
FLGB774ZMedicare PIN