Provider Demographics
NPI:1699422014
Name:JACKSON, MELISSA LYNN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 ELM ST # 1
Mailing Address - Street 2:
Mailing Address - City:LUDLOW
Mailing Address - State:KY
Mailing Address - Zip Code:41016-1494
Mailing Address - Country:US
Mailing Address - Phone:859-261-2210
Mailing Address - Fax:
Practice Address - Street 1:130 ELM ST
Practice Address - Street 2:
Practice Address - City:LUDLOW
Practice Address - State:KY
Practice Address - Zip Code:41016-1494
Practice Address - Country:US
Practice Address - Phone:859-261-2210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-05
Last Update Date:2022-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY022091183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist