Healthcare Provider Details

I. General information

NPI: 1023834371
Provider Name (Legal Business Name): MELISSA JACKSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 JACKSON ST
SAINT PAUL MN
55101-2502
US

IV. Provider business mailing address

640 JACKSON ST
SAINT PAUL MN
55101-2502
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-1611
  • Fax:
Mailing address:
  • Phone: 651-254-1611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number1850152
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: