Provider Demographics
NPI:1629139878
Name:MELILLO, JENNIFER L (PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:MELILLO
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6275 E VIRGINIA BEACH BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-2851
Mailing Address - Country:US
Mailing Address - Phone:757-961-0606
Mailing Address - Fax:757-233-8499
Practice Address - Street 1:6275 E VIRGINIA BEACH BLVD STE 300
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-2851
Practice Address - Country:US
Practice Address - Phone:757-961-0606
Practice Address - Fax:757-233-8499
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001160085163W00000X
VA0024169372363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1629139878Medicaid