Basic Information
| Provider Information | |||||||||
| NPI: | 1558332734 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | MELINDA | ||||||||
| MiddleName: | BROWN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4144 WYNTREE DR | ||||||||
| Address2: | |||||||||
| City: | NEWBURGH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 476302521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128581957 | ||||||||
| FaxNumber: | 8128581917 | ||||||||
| Practice Location | |||||||||
| Address1: | 4144 WYNTREE DR | ||||||||
| Address2: | |||||||||
| City: | NEWBURGH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 476302521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128581957 | ||||||||
| FaxNumber: | 8128581917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 01/23/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01037696 | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100180410 | 05 | IN | MEDICAID |