Provider Demographics
NPI:1073750204
Name:JACKSON, MELANI D (LPN)
Entity type:Individual
Prefix:MRS
First Name:MELANI
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2423 E GENESEE ST
Mailing Address - Street 2:2ND FL.
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2223
Mailing Address - Country:US
Mailing Address - Phone:315-474-0933
Mailing Address - Fax:
Practice Address - Street 1:2423 E GENESEE ST
Practice Address - Street 2:2ND FL.
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2223
Practice Address - Country:US
Practice Address - Phone:315-474-0933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY295456-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse