Provider Demographics
NPI:1952642639
Name:JACK, MELISSA (DAT, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:JACK
Suffix:
Gender:F
Credentials:DAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15826 ROXTON RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-2544
Mailing Address - Country:US
Mailing Address - Phone:484-515-5728
Mailing Address - Fax:
Practice Address - Street 1:15826 ROXTON RIDGE DR
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-2544
Practice Address - Country:US
Practice Address - Phone:484-515-5728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-06
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer