Active NPI
Mellissa Forde-Jackson, LCSW
- Clinical Social Worker
- Fayetteville, NC
National Provider Identifier
1922406842
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Social Worker
- License
- C010681
- Practice address
- 911 Hay St
Fayetteville, NC 28305-5313 - Phone
- (910) 827-6649
- Fax
- (910) 438-0942
- NPI assigned
- Dec 9, 2014
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | C010681 | NC | Primary |
Addresses
Primary practice location
911 Hay St
Fayetteville, NC 28305-5313
Mailing address
123 Harmony Hall Way
Fayetteville, NC 28303
Phone (706) 231-7025
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| C010681 | Other | NC | NORTH CAROLINA SOCIAL WORK CERTIFICATION AND LICENSURE BOARD |
Other names 1
- Mellissa Alysha Forde-Jackson
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in NC
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
Enrollment records 1
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| C010681 | NC | MD | Clinical Social Worker |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Grow Healthcare Group PA | Clinical | Current | Accepting new patients |
Locations
3511 Shannon Rd
Fl 3
Durham, NC 27707
Phone (201) 293-7689
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1418083200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1678233600000",
"number": "1922406842",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "123 HARMONY HALL WAY",
"city": "FAYETTEVILLE",
"state": "NC",
"postal_code": "28303",
"telephone_number": "706-231-7025"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "911 HAY ST",
"city": "FAYETTEVILLE",
"state": "NC",
"postal_code": "283055313",
"telephone_number": "910-827-6649",
"fax_number": "910-438-0942"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FORDE-JACKSON",
"first_name": "MELLISSA",
"credential": "LCSW",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2014-12-09",
"last_updated": "2023-03-08",
"certification_date": "2023-03-03",
"status": "A"
},
"taxonomies": [
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "NC",
"license": "C010681",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "NORTH CAROLINA SOCIAL WORK CERTIFICATION AND LICENSURE BOARD",
"identifier": "C010681",
"state": "NC"
}
],
"endpoints": [],
"other_names": [
{
"first_name": "MELLISSA",
"last_name": "FORDE-JACKSON",
"middle_name": "ALYSHA",
"credential": "LCSW",
"code": "2",
"type": "Professional Name"
}
]
}Other providers in Fayetteville, NC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 8, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.