Provider Demographics
NPI:1215288410
Name:MELTON, JENNIFER
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:MELTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13601 PRESTON RD
Mailing Address - Street 2:SUITE 415W
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240
Mailing Address - Country:US
Mailing Address - Phone:972-432-6550
Mailing Address - Fax:214-261-2217
Practice Address - Street 1:13601 PRESTON RD
Practice Address - Street 2:SUITE 415W
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240
Practice Address - Country:US
Practice Address - Phone:972-432-6550
Practice Address - Fax:214-261-2217
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1016859133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist