Basic Information
| Provider Information | |||||||||
| NPI: | 1053939595 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELLISH | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | KAITLYN | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 570 EGG HARBOR RD STE C4 | ||||||||
| Address2: | |||||||||
| City: | SEWELL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080802359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562560051 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 570 EGG HARBOR RD STE C4 | ||||||||
| Address2: | |||||||||
| City: | SEWELL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080802359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562560051 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2020 | ||||||||
| LastUpdateDate: | 07/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 46TR00923000 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.