Provider Demographics
NPI:1851160253
Name:JACKSON, MELISSA M (LCSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 BULLIS AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-5233
Mailing Address - Country:US
Mailing Address - Phone:228-697-3953
Mailing Address - Fax:
Practice Address - Street 1:2715 BULLIS AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-5233
Practice Address - Country:US
Practice Address - Phone:228-697-3953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC108241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical