=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194383307
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA MELLARD M.S. NCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2019
-----------------------------------------------------
Last Update Date | 07/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 224 OLD MILL RD
-----------------------------------------------------
City | WARTBURG
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37887-4163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-346-6221
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 HENLEY RD
-----------------------------------------------------
City | OAK RIDGE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37830-5004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-236-2006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------