MEDICARE: MELODY JACKMAN MA, CMHC

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	C5858	OR

General Provider Information

NPI Number	:	1891245403
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELODY JACKMAN MA, CMHC

Provider Business Mailing Address
First Line	:	10700 SW BEAVERTON HILLSDALE HWY STE 460
Second Line	:
City	:	BEAVERTON
State	:	OR
Zip	:	97005-4736
Country	:	US
Telephone Number	:	503-999-1362
Fax Number	:

Provider Business Practice Location Address
First Line	:	10700 SW BEAVERTON HILLSDALE HWY STE 460
Second Line	:
City	:	BEAVERTON
State	:	OR
Zip	:	97005-4736
Country	:	US
Telephone Number	:	503-999-1362
Fax Number	:

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

Provider Enumeration Date	:	10/06/2016
Last Update Date	:	08/16/2021

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