Provider Demographics
NPI:1972750073
Name:JACKSON, MELINDA W (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 HIGHWAY 34 E
Mailing Address - Street 2:STE 1300
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-3186
Mailing Address - Country:US
Mailing Address - Phone:770-304-3880
Mailing Address - Fax:
Practice Address - Street 1:345 SHORELINE CIR
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-5940
Practice Address - Country:US
Practice Address - Phone:770-304-3880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-20
Last Update Date:2017-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002469225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics