Provider Demographics
NPI:1861605339
Name:JACKSON, MELODY LYN (RDHAP)
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:LYN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 BROADVIEW ST
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-5522
Mailing Address - Country:US
Mailing Address - Phone:619-246-3491
Mailing Address - Fax:619-434-6288
Practice Address - Street 1:630 BROADVIEW ST
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977-5522
Practice Address - Country:US
Practice Address - Phone:619-246-3491
Practice Address - Fax:619-434-6288
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist