Basic Information
| Provider Information | |||||||||
| NPI: | 1851945109 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON-SHADE | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | |||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 TANGLEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | SICKLERVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080811161 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 770 WOODLANE RD | ||||||||
| Address2: | |||||||||
| City: | WESTAMPTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080603804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568810399 | ||||||||
| FaxNumber: | 8568811033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2019 | ||||||||
| LastUpdateDate: | 07/25/2019 | ||||||||
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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 | 163W00000X | 26NO12017700 | NJ | Y | Nursing Service Providers | Registered Nurse |
No ID Information.