Provider Demographics
NPI:1730281676
Name:JACKSON, MELVIN ALLEN SR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MELVIN
Middle Name:ALLEN
Last Name:JACKSON
Suffix:SR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17325 NW 9TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5201
Mailing Address - Country:US
Mailing Address - Phone:305-623-0290
Mailing Address - Fax:
Practice Address - Street 1:1492 W FLAGLER ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-2209
Practice Address - Country:US
Practice Address - Phone:305-541-8435
Practice Address - Fax:305-541-6974
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW13911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical