Provider Demographics
NPI:1841765708
Name:MELTON, JENNIFER ANN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:MELTON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 EOLA DR
Mailing Address - Street 2:
Mailing Address - City:YAZOO CITY
Mailing Address - State:MS
Mailing Address - Zip Code:39194-8203
Mailing Address - Country:US
Mailing Address - Phone:601-456-0023
Mailing Address - Fax:601-510-9065
Practice Address - Street 1:200 S MAIN ST
Practice Address - Street 2:
Practice Address - City:YAZOO CITY
Practice Address - State:MS
Practice Address - Zip Code:39194-4010
Practice Address - Country:US
Practice Address - Phone:601-456-0023
Practice Address - Fax:601-510-9065
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09057372Medicaid