MEDICARE: MELANIE J JACKSON MS, LMHC, NCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH 3045	FL
2	101Y00000X	Counselor	NCC 33945	NC
3	101YP2500X	Professional Counselor	18548	TX

General Provider Information

NPI Number	:	1013228600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELANIE J JACKSON MS, LMHC, NCC

Provider Business Mailing Address
First Line	:	5840 RED BUG LAKE RD
Second Line	:	#1548
City	:	WINTER SPRINGS
State	:	FL
Zip	:	32708-5011
Country	:	US
Telephone Number	:	423-342-6422
Fax Number	:	407-695-8803

Provider Business Practice Location Address
First Line	:	5840 RED BUG LAKE RD
Second Line	:	#1548
City	:	WINTER SPRINGS
State	:	FL
Zip	:	32708-5011
Country	:	US
Telephone Number	:	423-342-6422
Fax Number	:	407-695-8803

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2010
Last Update Date	:	06/08/2020

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