Provider Demographics
NPI:1104908052
Name:MELLE, JENNIFER LYNN (LMP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:MELLE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15308 CASCADIAN WAY
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98087-2136
Mailing Address - Country:US
Mailing Address - Phone:425-743-9731
Mailing Address - Fax:425-918-1418
Practice Address - Street 1:15308 CASCADIAN WAY
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98087-2136
Practice Address - Country:US
Practice Address - Phone:425-743-9731
Practice Address - Fax:425-918-1418
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00000949174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist