Provider Demographics
NPI:1992048482
Name:JACKSON, MELISSA MICHELLE (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:MICHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 MARIE AVE
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-2715
Mailing Address - Country:US
Mailing Address - Phone:985-209-1827
Mailing Address - Fax:
Practice Address - Street 1:707 MARIE AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-2715
Practice Address - Country:US
Practice Address - Phone:985-209-1827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6800235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist