Provider Demographics
NPI:1750769659
Name:JACKSON, MELANIE (MD)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:
Other - Last Name:GRANDSTAFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:325 MEDICAL PKWY STE 200
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-2457
Practice Address - Country:US
Practice Address - Phone:864-797-9550
Practice Address - Fax:864-797-9555
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-11
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC52048207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program