Healthcare Provider Details

I. General information

NPI: 1235808551
Provider Name (Legal Business Name): MELISSA EILEEN JACKSON LPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 09/20/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71175 AURORA RD
DESERT HOT SPRINGS CA
92241-7631
US

IV. Provider business mailing address

71175 AURORA RD
DESERT HOT SPRINGS CA
92241-7631
US

V. Phone/Fax

Practice location:
  • Phone: 760-251-8858
  • Fax: 760-329-8889
Mailing address:
  • Phone: 760-251-8858
  • Fax: 760-329-8889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License NumberBVNPT
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number35652
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: