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NPI Code Detail

MEDICARE: MRS. MELISSA M MOUTON-JACKSON

MEDICARE: MRS. MELISSA M MOUTON-JACKSON
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
1101YA0400XAddiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number : 1073026894
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. MELISSA M MOUTON-JACKSON
Provider Business Mailing Address
First Line : 2118 S CENTRAL AVE
Second Line :
City : LOS ANGELES
State : CA
Zip : 90011-1237
Country : US
Telephone Number : 213-493-4664
Fax Number : 213-493-4665
Provider Business Practice Location Address
First Line : 2118 S CENTRAL AVE
Second Line :
City : LOS ANGELES
State : CA
Zip : 90011-1237
Country : US
Telephone Number : 213-493-4664
Fax Number : 213-493-4665
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/15/2017
Last Update Date : 11/15/2017

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