Provider Demographics
NPI:1801174008
Name:SELF, JENNIFER MELAINA (PHD, PMHNP-BC, LMHC)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MELAINA
Last Name:SELF
Suffix:
Gender:F
Credentials:PHD, PMHNP-BC, LMHC
Other - Prefix:
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Mailing Address - Street 1:8200 BAYSHORE DR APT 1
Mailing Address - Street 2:
Mailing Address - City:TREASURE ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:33706-5231
Mailing Address - Country:US
Mailing Address - Phone:314-239-8190
Mailing Address - Fax:
Practice Address - Street 1:28465 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-2511
Practice Address - Country:US
Practice Address - Phone:727-600-8093
Practice Address - Fax:727-240-0604
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2002032344101YM0800X
FL17148101YM0800X
FL11017864363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health