Healthcare Provider Details

I. General information

NPI: 1700064797
Provider Name (Legal Business Name): MELINDA JACKSON MD PHD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2008
Last Update Date: 02/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4144 WYNTREE DR
NEWBURGH IN
47630-2521
US

IV. Provider business mailing address

4144 WYNTREE DR
NEWBURGH IN
47630-2521
US

V. Phone/Fax

Practice location:
  • Phone: 812-858-1957
  • Fax: 812-858-1917
Mailing address:
  • Phone: 812-858-1957
  • Fax: 812-858-1917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01037696A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71002200A
License Number StateIN

VIII. Authorized Official

Name: DR. MELINDA BROWN JACKSON
Title or Position: OWNER/PHYSICIAN
Credential: MD,PHD
Phone: 812-858-1957