Provider Demographics
NPI:1689470254
Name:MELLOH, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MELLOH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 RED COACH DR
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-8307
Mailing Address - Country:US
Mailing Address - Phone:574-387-4313
Mailing Address - Fax:
Practice Address - Street 1:15755 N POINTE BLVD
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-4388
Practice Address - Country:US
Practice Address - Phone:574-387-4313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-23-304231106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician