Provider Demographics
NPI:1154959336
Name:MELLIS, JACQUELYN M (LCSW)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:M
Last Name:MELLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8534 SAGAMORE DR.
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:MO
Mailing Address - Zip Code:63016
Mailing Address - Country:US
Mailing Address - Phone:636-288-9737
Mailing Address - Fax:636-274-9332
Practice Address - Street 1:2634 HWY 109
Practice Address - Street 2:SUITE E
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040
Practice Address - Country:US
Practice Address - Phone:314-384-6534
Practice Address - Fax:636-274-9332
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-01
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0012521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical