Provider Demographics
NPI:1891235933
Name:JACKSON, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21332 TARRACO
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-5921
Mailing Address - Country:US
Mailing Address - Phone:317-345-5802
Mailing Address - Fax:949-600-6999
Practice Address - Street 1:21332 TARRACO
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92692-5921
Practice Address - Country:US
Practice Address - Phone:317-345-5802
Practice Address - Fax:949-600-6999
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-07
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122531106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist