Provider Demographics
NPI:1245701127
Name:JACKSON-WESTBROOK, MELISSA ANN (PSYD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:JACKSON-WESTBROOK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1240 SAPPONY DR APT 205
Mailing Address - Street 2:
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-6532
Mailing Address - Country:US
Mailing Address - Phone:757-434-6599
Mailing Address - Fax:
Practice Address - Street 1:10580 LIGON MILL RD STE 210
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6090
Practice Address - Country:US
Practice Address - Phone:919-263-9592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5468103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical