Provider Demographics
NPI:1780005793
Name:MELLINGER, JENNIFER LEIGH (DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEIGH
Last Name:MELLINGER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEIGH
Other - Last Name:GEBHARDT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:24630 WASHINGTON AVE
Mailing Address - Street 2:STE. 200
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6131
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:28780 SINGLE OAK DR
Practice Address - Street 2:STE. 290
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-3625
Practice Address - Country:US
Practice Address - Phone:951-693-5871
Practice Address - Fax:951-693-5872
Is Sole Proprietor?:No
Enumeration Date:2013-12-17
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT40800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist