Provider Demographics
NPI:1295080927
Name:MELANCON, JENNIFER (PT,DPT,CKTP)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:MELANCON
Suffix:
Gender:F
Credentials:PT,DPT,CKTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3149 AMBASSADOR CAFFERY PKWY
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-7209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3149 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-7209
Practice Address - Country:US
Practice Address - Phone:337-706-3455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2017-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09043R225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX13792080Medicaid