Provider Demographics
NPI:1598212078
Name:MELLIN, JERRY F (MA)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:F
Last Name:MELLIN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4394 N PRAIRIE WILLOW CT
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94521-4439
Mailing Address - Country:US
Mailing Address - Phone:925-787-8865
Mailing Address - Fax:
Practice Address - Street 1:2702 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94519-2789
Practice Address - Country:US
Practice Address - Phone:925-798-9240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF93904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist