Provider Demographics
NPI:1093128597
Name:MELANCON, JEAN
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:MELANCON
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 1:800 SAGUARO TRL
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-9632
Mailing Address - Country:US
Mailing Address - Phone:888-873-4221
Mailing Address - Fax:
Practice Address - Street 1:800 SAGUARO TRL
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-9632
Practice Address - Country:US
Practice Address - Phone:888-873-4221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-0914225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant