Provider Demographics
NPI:1578049276
Name:JACKSON, MELISSA BARHAM (NP)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:BARHAM
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:MAE
Other - Last Name:BARHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-4560
Mailing Address - Fax:601-200-4580
Practice Address - Street 1:971 LAKELAND DR STE 557
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4661
Practice Address - Country:US
Practice Address - Phone:601-200-4560
Practice Address - Fax:601-200-4580
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902715363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04520717Medicaid