Provider Demographics
NPI:1952757726
Name:JACKSON, MELODEE (PT , DPT)
Entity Type:Individual
Prefix:
First Name:MELODEE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT , DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 MEDICAL GROUP
Mailing Address - Street 2:15301 WARREN SHINGLE ROAD
Mailing Address - City:BEALE AFB
Mailing Address - State:CA
Mailing Address - Zip Code:95903-1907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9 MEDICAL GROUP
Practice Address - Street 2:15301 WARREN SHINGLE ROAD
Practice Address - City:BEALE AFB
Practice Address - State:CA
Practice Address - Zip Code:95903-1907
Practice Address - Country:US
Practice Address - Phone:503-634-4826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT30626225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist