Provider Demographics
NPI:1932128808
Name:MELLIN, JENNIFER S (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:MELLIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 LAKEWOOD DR
Mailing Address - Street 2:STE A
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-3352
Mailing Address - Country:US
Mailing Address - Phone:815-942-6323
Mailing Address - Fax:815-942-6323
Practice Address - Street 1:518 LUCINDA AVE
Practice Address - Street 2:NIU HEALTH SERVICES
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115
Practice Address - Country:US
Practice Address - Phone:815-753-9587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361115122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCE9335OtherRR GROUP
ILP00345212OtherRR MEDICARE #
ILCE9335OtherRR GROUP
ILH22873Medicare UPIN