Provider Demographics
NPI:1598423774
Name:JACKSON, MELINDA MARIE (ARNP, FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ARNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 RED OAK ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:IA
Mailing Address - Zip Code:52057-9401
Mailing Address - Country:US
Mailing Address - Phone:563-608-4481
Mailing Address - Fax:563-822-1052
Practice Address - Street 1:1212 W MARION ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:IA
Practice Address - Zip Code:52057-2314
Practice Address - Country:US
Practice Address - Phone:563-822-0081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-04
Last Update Date:2024-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA166588363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAA166588OtherARNP