Provider Demographics
NPI:1972750073
Name:JACKSON, MELINDA W (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 CLINIC AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4402
Mailing Address - Country:US
Mailing Address - Phone:770-834-0873
Mailing Address - Fax:
Practice Address - Street 1:1124 N PARK ST STE M
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-2282
Practice Address - Country:US
Practice Address - Phone:770-834-0873
Practice Address - Fax:770-834-6118
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-20
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT002649225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist