Basic Information
| Provider Information | |||||||||
| NPI: | 1669647913 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | M HOPE JACKSON PHD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2864 DAUPHIN ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366062479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514707607 | ||||||||
| FaxNumber: | 2514707609 | ||||||||
| Practice Location | |||||||||
| Address1: | 2864 DAUPHIN ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366062479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514707607 | ||||||||
| FaxNumber: | 2514707609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2008 | ||||||||
| LastUpdateDate: | 04/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | MELANIE | ||||||||
| AuthorizedOfficialMiddleName: | HOPE | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 2514707607 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 1369 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1619953726 | 01 | AL | TYPE 1 NPI | OTHER |