Provider Demographics
NPI:1902203557
Name:JACKSON, MELODY FELISSA
Entity Type:Individual
Prefix:MRS
First Name:MELODY
Middle Name:FELISSA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MELODY
Other - Middle Name:FELISSA
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP/MSN
Mailing Address - Street 1:21150 NE MIAMI CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33179-1033
Mailing Address - Country:US
Mailing Address - Phone:305-585-5143
Mailing Address - Fax:
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-585-5143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL211763163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics