Provider Demographics
NPI:1043324866
Name:JACKSON, MELISSA KAE (PT)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:KAE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:131 LAWRENCE ST
Mailing Address - Street 2:OUTPATIENT THERAPIES
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-1346
Mailing Address - Country:US
Mailing Address - Phone:518-691-1451
Mailing Address - Fax:518-691-1460
Practice Address - Street 1:131 LAWRENCE ST
Practice Address - Street 2:OUTPATIENT THERAPIES
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-1346
Practice Address - Country:US
Practice Address - Phone:518-691-1451
Practice Address - Fax:518-691-1460
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0183161225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist