Provider Demographics
NPI:1790280113
Name:JACKSON, MELISSA (PHARMD)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:NACU
Other - Last Name:WELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1350 S MAIN ST STE 1600
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7663
Mailing Address - Country:US
Mailing Address - Phone:817-702-4663
Mailing Address - Fax:
Practice Address - Street 1:1350 S MAIN ST STE 1600
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-7663
Practice Address - Country:US
Practice Address - Phone:817-702-4663
Practice Address - Fax:817-702-6924
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67006183500000X, 1835I0206X, 1835P2201X, 1835P0018X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No1835I0206XPharmacy Service ProvidersPharmacistInfectious Diseases
No1835P2201XPharmacy Service ProvidersPharmacistAmbulatory CareGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty