Healthcare Provider Details

I. General information

NPI: 1679451249
Provider Name (Legal Business Name): MELVIN JACKSON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 POPLAR RD
NEWNAN GA
30265-1618
US

IV. Provider business mailing address

1066 ALMA DR
MACON GA
31216-6195
US

V. Phone/Fax

Practice location:
  • Phone: 770-400-2353
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN-NP309363
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN309363
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: