Healthcare Provider Details

I. General information

NPI: 1588183040
Provider Name (Legal Business Name): MELISSA KAY JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2017
Last Update Date: 09/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 MARTIN LUTHER KING JR BLVD
EUGENE OR
97401-5824
US

IV. Provider business mailing address

3515 MILL ST
EUGENE OR
97405-3864
US

V. Phone/Fax

Practice location:
  • Phone: 541-683-3608
  • Fax:
Mailing address:
  • Phone: 541-517-4388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: