Provider Demographics
NPI:1316601511
Name:JACKSON, MELODY
Entity type:Individual
Prefix:MS
First Name:MELODY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1667 N ALLISON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-3530
Mailing Address - Country:US
Mailing Address - Phone:267-658-9971
Mailing Address - Fax:
Practice Address - Street 1:1667 N ALLISON ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-3530
Practice Address - Country:US
Practice Address - Phone:267-658-9971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA61203601251E00000X, 376J00000X, 385H00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA61203601Medicaid