Provider Demographics
NPI:1356090567
Name:MELLON, JESSICA (LCPC-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MELLON
Suffix:
Gender:F
Credentials:LCPC-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 FLYING POINT RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-6435
Mailing Address - Country:US
Mailing Address - Phone:207-577-7527
Mailing Address - Fax:
Practice Address - Street 1:15 FLYING POINT RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-6435
Practice Address - Country:US
Practice Address - Phone:207-577-7527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL6564101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health