Basic Information
| Provider Information | |||||||||
| NPI: | 1245701127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON-WESTBROOK | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PSY.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | JACKSON | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1240 SAPPONY DR APT 205 | ||||||||
| Address2: | |||||||||
| City: | KNIGHTDALE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275456532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574346599 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10580 LIGON MILL RD STE 210 | ||||||||
| Address2: | |||||||||
| City: | WAKE FOREST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275876090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192639592 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2018 | ||||||||
| LastUpdateDate: | 01/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 5468 | NC | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | 5468 | NC | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.