Provider Demographics
NPI:1861482226
Name:MELLOTT, JILL (OT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:MELLOTT
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:CERNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:202 CARSON AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2342
Mailing Address - Country:US
Mailing Address - Phone:719-589-5149
Mailing Address - Fax:719-589-3717
Practice Address - Street 1:202 CARSON AVE
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2342
Practice Address - Country:US
Practice Address - Phone:719-589-5149
Practice Address - Fax:719-589-3717
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1009493225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCE654889OtherANTHEM BCBS
CO840706945104OtherROCKY MOUNTAIN HEALTH PLA