Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225X00000X | Occupational Therapist | 17-02390 | KS |
Y | 225XH1200X | Occupational Therapist - Hand | 2008014106 | MO |
NPI | 1174711550 |
---|---|
Provider Name | Melanie L Jackson |
First Address | Lees Summit, MO 64086-4714 |
Second Address | Lees Summit, MO 64086-4714 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2007 |
Last Update Date | 17/09/2014 |