Provider Demographics
NPI:1194432914
Name:MELANCON, JENNIFER (LMT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:MELANCON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E SAINT PETER ST
Mailing Address - Street 2:
Mailing Address - City:CARENCRO
Mailing Address - State:LA
Mailing Address - Zip Code:70520-4008
Mailing Address - Country:US
Mailing Address - Phone:337-520-2505
Mailing Address - Fax:
Practice Address - Street 1:101 E SAINT PETER ST
Practice Address - Street 2:
Practice Address - City:CARENCRO
Practice Address - State:LA
Practice Address - Zip Code:70520-4008
Practice Address - Country:US
Practice Address - Phone:337-520-2505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAE4815225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty