Provider Demographics
NPI:1558330647
Name:JACKSON, MELINDA ANN
Entity Type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:MELINDA
Other - Middle Name:ANN
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:13007 NE GLISAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-2545
Mailing Address - Country:US
Mailing Address - Phone:503-215-6556
Mailing Address - Fax:503-215-0685
Practice Address - Street 1:13007 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-2545
Practice Address - Country:US
Practice Address - Phone:503-215-6556
Practice Address - Fax:503-215-0685
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12772207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine