Healthcare Provider Details

I. General information

NPI: 1891508925
Provider Name (Legal Business Name): MARY JEANNE MCLELLAN DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2025
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

486 TOWN PLAZA AVE STE 410
PONTE VEDRA BEACH FL
32081-5141
US

IV. Provider business mailing address

558 WOODGROVE ST
ORMOND BEACH FL
32174-8458
US

V. Phone/Fax

Practice location:
  • Phone: 904-686-7142
  • Fax:
Mailing address:
  • Phone: 386-341-4089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number15339
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: