Provider Demographics
NPI:1275788663
Name:MELLOR, JESSE R (LADC)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:R
Last Name:MELLOR
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-1529
Mailing Address - Country:US
Mailing Address - Phone:508-799-2934
Mailing Address - Fax:508-770-1732
Practice Address - Street 1:44 FRONT ST
Practice Address - Street 2:490
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1733
Practice Address - Country:US
Practice Address - Phone:508-799-2934
Practice Address - Fax:508-770-1732
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-26
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA114101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)