Provider Demographics
NPI:1386995108
Name:MELLIS, JENNIFER RENEA (PT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:RENEA
Last Name:MELLIS
Suffix:
Gender:
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6622 GORDON RD STE L
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-8415
Mailing Address - Country:US
Mailing Address - Phone:910-407-7211
Mailing Address - Fax:
Practice Address - Street 1:6622 GORDON RD STE L
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-8415
Practice Address - Country:US
Practice Address - Phone:910-407-7211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6747225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist