Provider Demographics
NPI:1942421557
Name:JACKSON, MELANIE B (LPN)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:B
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 SHADY LANE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30292
Mailing Address - Country:US
Mailing Address - Phone:770-227-3085
Mailing Address - Fax:
Practice Address - Street 1:605 WEST GORDON
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286
Practice Address - Country:US
Practice Address - Phone:770-358-5252
Practice Address - Fax:706-646-6039
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN031091164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse