Provider Demographics
NPI:1851873889
Name:MELLO, JESSICA (DIRECTOR/OWNER)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MELLO
Suffix:
Gender:F
Credentials:DIRECTOR/OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12904 BRENTWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-8501
Mailing Address - Country:US
Mailing Address - Phone:218-393-4855
Mailing Address - Fax:
Practice Address - Street 1:12904 BRENTWOOD CIR
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-8501
Practice Address - Country:US
Practice Address - Phone:218-393-4855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health