Provider Demographics
NPI:1679974893
Name:MELON, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MELON
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 1:28 JOHN DR
Mailing Address - Street 2:
Mailing Address - City:OLD BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11804-1541
Mailing Address - Country:US
Mailing Address - Phone:516-318-6178
Mailing Address - Fax:
Practice Address - Street 1:3141 LEE PL
Practice Address - Street 2:SUITE 2
Practice Address - City:BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-5037
Practice Address - Country:US
Practice Address - Phone:646-327-2723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-07
Last Update Date:2014-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY771803131103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst