Provider Demographics
NPI:1700113446
Name:SALEM-JACKSON, MELINDA (NCTMB, LMT, CMMT)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:SALEM-JACKSON
Suffix:
Gender:F
Credentials:NCTMB, LMT, CMMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2695 VZ COUNTY ROAD 4923
Mailing Address - Street 2:
Mailing Address - City:BEN WHEELER
Mailing Address - State:TX
Mailing Address - Zip Code:75754-4440
Mailing Address - Country:US
Mailing Address - Phone:903-368-4200
Mailing Address - Fax:
Practice Address - Street 1:2695 VAN ZANDT CR 4923
Practice Address - Street 2:
Practice Address - City:BEN WHEELER
Practice Address - State:TX
Practice Address - Zip Code:75754-4440
Practice Address - Country:US
Practice Address - Phone:903-368-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-17
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-08893225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMT-116546OtherSTATE LICENSE