Healthcare Provider Details

I. General information

NPI: 1073026894
Provider Name (Legal Business Name): MRS. MELISSA M MOUTON-JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2017
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2118 S CENTRAL AVE
LOS ANGELES CA
90011-1237
US

IV. Provider business mailing address

2118 S CENTRAL AVE
LOS ANGELES CA
90011-1237
US

V. Phone/Fax

Practice location:
  • Phone: 213-493-4664
  • Fax: 213-493-4665
Mailing address:
  • Phone: 213-493-4664
  • Fax: 213-493-4665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: