Provider Demographics
NPI:1912106733
Name:JACKSON, MELISSA (PHD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:CARMEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:29 W FULTON ST STE D
Mailing Address - Street 2:
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078-2937
Mailing Address - Country:US
Mailing Address - Phone:518-313-6105
Mailing Address - Fax:
Practice Address - Street 1:29 W FULTON ST STE D
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-2937
Practice Address - Country:US
Practice Address - Phone:518-313-6105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018244103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling