Provider Demographics
NPI:1609145184
Name:JACKSON, MELISSA RENA (MHR, LPC)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:RENA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MHR, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11541 VILLAGE AVE
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-8207
Mailing Address - Country:US
Mailing Address - Phone:405-201-3646
Mailing Address - Fax:
Practice Address - Street 1:11541 VILLAGE AVE
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-8207
Practice Address - Country:US
Practice Address - Phone:405-201-3646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator