Provider Demographics
NPI:1396212544
Name:MELLUM, JENNIFER JO (LMHC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JO
Last Name:MELLUM
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28923 N 124TH GLN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-0366
Mailing Address - Country:US
Mailing Address - Phone:808-463-2765
Mailing Address - Fax:
Practice Address - Street 1:702 E BELL RD STE 107
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-6639
Practice Address - Country:US
Practice Address - Phone:602-482-7311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60899386101Y00000X
WALH61109476101YM0800X
AZLPC22918101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health