Healthcare Provider Details

I. General information

NPI: 1093298655
Provider Name (Legal Business Name): MELISSA MARIE JACKSON RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 09/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 W 68TH ST
KANSAS CITY MO
64113-1919
US

IV. Provider business mailing address

456 W 68TH ST
KANSAS CITY MO
64113-1919
US

V. Phone/Fax

Practice location:
  • Phone: 816-729-0048
  • Fax:
Mailing address:
  • Phone: 816-729-0048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number2008031019
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: