Provider Demographics
NPI:1295946093
Name:JACKSON, MELISSA REYES (MED)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:REYES
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8816 W LAS PALMARITAS DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-7808
Mailing Address - Country:US
Mailing Address - Phone:602-764-6052
Mailing Address - Fax:
Practice Address - Street 1:3839 W CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85019-2512
Practice Address - Country:US
Practice Address - Phone:602-764-6052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ897796Medicaid