Provider Demographics
NPI:1255981049
Name:MELLOTT, JENNY ELIZABETH (SLP)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:ELIZABETH
Last Name:MELLOTT
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 GRAVES DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:NV
Mailing Address - Zip Code:89403-6300
Mailing Address - Country:US
Mailing Address - Phone:925-437-8098
Mailing Address - Fax:
Practice Address - Street 1:16 GRAVES DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:NV
Practice Address - Zip Code:89403-6300
Practice Address - Country:US
Practice Address - Phone:925-437-8098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-13
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8724235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV3229087230Medicaid