Provider Demographics
NPI:1558332734
Name:JACKSON, MELINDA BROWN (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MELINDA
Middle Name:BROWN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4144 WYNTREE DR
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-2521
Mailing Address - Country:US
Mailing Address - Phone:812-858-1957
Mailing Address - Fax:812-858-1917
Practice Address - Street 1:4144 WYNTREE DR
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-2521
Practice Address - Country:US
Practice Address - Phone:812-858-1957
Practice Address - Fax:812-858-1917
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037696207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100180410Medicaid
IN882230Medicare ID - Type Unspecified
IN100180410Medicaid