Individual
MELVIN JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
2415 N 124TH CIR, AVONDALE, AZ 85392-6509
(602) 841-3438
Mailing address
2415 N 124TH CIR, AVONDALE, AZ 85392-6509
(602) 841-3438
Taxonomy
Speciality
Code
Description
License number
State
322D00000X
Emotionally Disturbed Childrens' Residential Treatment Facility
Primary
11297
AZ
Other
Enumeration date
01/19/2009
Last updated
01/19/2009
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