Provider Demographics
NPI:1922406842
Name:FORDE-JACKSON, MELLISSA (LCSW)
Entity Type:Individual
Prefix:
First Name:MELLISSA
Middle Name:
Last Name:FORDE-JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MELLISSA
Other - Middle Name:ALYSHA
Other - Last Name:FORDE-JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:123 HARMONY HALL WAY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303
Mailing Address - Country:US
Mailing Address - Phone:706-231-7025
Mailing Address - Fax:
Practice Address - Street 1:911 HAY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5313
Practice Address - Country:US
Practice Address - Phone:910-827-6649
Practice Address - Fax:910-438-0942
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-09
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0106811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC010681OtherNORTH CAROLINA SOCIAL WORK CERTIFICATION AND LICENSURE BOARD