=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013228600
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELANIE J JACKSON MS, LMHC, NCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2010
-----------------------------------------------------
Last Update Date | 06/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5840 RED BUG LAKE RD #1548
-----------------------------------------------------
City | WINTER SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32708-5011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-342-6422
-----------------------------------------------------
Fax | 407-695-8803
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5840 RED BUG LAKE RD #1548
-----------------------------------------------------
City | WINTER SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32708-5011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-342-6422
-----------------------------------------------------
Fax | 407-695-8803
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH 3045
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | NCC 33945
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 18548
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------