Provider Demographics
NPI:1174711550
Name:JACKSON, MELANIE L (MOTR/L, CHT)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MOTR/L, CHT
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:L
Other - Last Name:MATZEDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 NE MISSOURI RD
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-4714
Mailing Address - Country:US
Mailing Address - Phone:816-836-2500
Mailing Address - Fax:816-836-2525
Practice Address - Street 1:300 NE MISSOURI RD
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-4714
Practice Address - Country:US
Practice Address - Phone:816-836-2500
Practice Address - Fax:816-836-2525
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-02390225X00000X
MO2008014106225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist