MEDICARE: MELODY LYN JACKSON RDHAP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist

General Provider Information

NPI Number	:	1861605339
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELODY LYN JACKSON RDHAP

Provider Business Mailing Address
First Line	:	630 BROADVIEW ST
Second Line	:
City	:	SPRING VALLEY
State	:	CA
Zip	:	91977-5522
Country	:	US
Telephone Number	:	619-246-3491
Fax Number	:	619-434-6288

Provider Business Practice Location Address
First Line	:	630 BROADVIEW ST
Second Line	:
City	:	SPRING VALLEY
State	:	CA
Zip	:	91977-5522
Country	:	US
Telephone Number	:	619-246-3491
Fax Number	:	619-434-6288

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2007
Last Update Date	:	07/08/2007

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