Provider Demographics
NPI:1124297270
Name:MIGNOGNA, MELISSA R (PHD)
Entity type:Individual
Prefix:PROF
First Name:MELISSA
Middle Name:R
Last Name:MIGNOGNA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MELISSA
Other - Middle Name:R
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:6541 CASCADE DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-4302
Mailing Address - Country:US
Mailing Address - Phone:405-612-8574
Mailing Address - Fax:
Practice Address - Street 1:111 VISION PARK BLVD
Practice Address - Street 2:SUITE 250
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77384-3002
Practice Address - Country:US
Practice Address - Phone:281-528-4226
Practice Address - Fax:281-419-0921
Is Sole Proprietor?:No
Enumeration Date:2008-02-22
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36831103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist