Active NPI
Jacquelyn M Mellis, LCSW
- Clinical Social Worker
- Wildwood, MO
National Provider Identifier
1154959336
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Social Worker
- License
- 001252
- Practice address
- 2634 Hwy 109
Suite E
Wildwood, MO 63040 - Phone
- (314) 384-6534
- Fax
- (636) 274-9332
- NPI assigned
- Apr 1, 2020
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | 001252 | MO | Primary |
Addresses
Primary practice location
2634 Hwy 109
Suite E
Wildwood, MO 63040
Mailing address
8534 Sagamore Dr.
Cedar Hill, MO 63016
Phone (636) 288-9737
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 001252 | MO | MD | Clinical Social Worker |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1585699200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1587340800000",
"number": "1154959336",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "8534 SAGAMORE DR.",
"city": "CEDAR HILL",
"state": "MO",
"postal_code": "63016",
"telephone_number": "636-288-9737",
"fax_number": "636-274-9332"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2634 HWY 109",
"address_2": "SUITE E",
"city": "WILDWOOD",
"state": "MO",
"postal_code": "63040",
"telephone_number": "314-384-6534",
"fax_number": "636-274-9332"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MELLIS",
"first_name": "JACQUELYN",
"middle_name": "M",
"credential": "LCSW",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2020-04-01",
"last_updated": "2020-04-20",
"certification_date": "2020-04-20",
"status": "A"
},
"taxonomies": [
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "MO",
"license": "001252",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Wildwood, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 20, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.