Provider Demographics
NPI:1619066982
Name:JACKSON, MELISSA FAYE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:FAYE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:75 RIVERFRONT DR
Mailing Address - Street 2:438
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72114-5948
Mailing Address - Country:US
Mailing Address - Phone:205-565-1694
Mailing Address - Fax:
Practice Address - Street 1:2024 ARKANSAS VALLEY DR
Practice Address - Street 2:STE 206
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-4166
Practice Address - Country:US
Practice Address - Phone:501-246-7171
Practice Address - Fax:501-246-7171
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AR12-19P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510-04551OtherBLUE CROSS BLUE SHIELD