Provider Demographics
NPI:1891590329
Name:MELLEMA, JESSE S
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:S
Last Name:MELLEMA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16681 LYNN LN APT A
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-3461
Mailing Address - Country:US
Mailing Address - Phone:714-334-6685
Mailing Address - Fax:
Practice Address - Street 1:16561 BOLSA CHICA ST STE 100
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-3594
Practice Address - Country:US
Practice Address - Phone:714-364-1313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-18
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3076462251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic