MEDICARE: MELISSA GRACE 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
1	101Y00000X	Counselor

General Provider Information

NPI Number	:	1205367737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA GRACE JACKSON

Provider Business Mailing Address
First Line	:	1601 W BALBOA BLVD
Second Line	:	APT D
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92663-4527
Country	:	US
Telephone Number	:	949-723-2388
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 W BALBOA BLVD
Second Line	:	APT D
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92663-4527
Country	:	US
Telephone Number	:	949-723-2388
Fax Number	:

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

Provider Enumeration Date	:	03/26/2017
Last Update Date	:	03/26/2017

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