Provider Demographics
NPI:1730337007
Name:MELANCON, JESSICA CANALES (MPT)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:CANALES
Last Name:MELANCON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2130 OLVEY DR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-1066
Mailing Address - Country:US
Mailing Address - Phone:985-626-9938
Mailing Address - Fax:989-626-9938
Practice Address - Street 1:340 FALCONER DR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-8204
Practice Address - Country:US
Practice Address - Phone:985-893-2845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2010-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04697225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
3B263CP75Medicare PIN