Provider Demographics
NPI:1710037395
Name:JACKSON, MELVORA (MPA)
Entity Type:Individual
Prefix:MRS
First Name:MELVORA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 MORISSETTE WAY
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-7326
Mailing Address - Country:US
Mailing Address - Phone:925-335-4764
Mailing Address - Fax:925-335-4759
Practice Address - Street 1:1000 WARD ST
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-1360
Practice Address - Country:US
Practice Address - Phone:925-335-4764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical