Provider Demographics
NPI:1447295233
Name:MELLOTT, JANE K (MD)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:K
Last Name:MELLOTT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:KERNIE
Other - Last Name:MELLOTT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:209 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4265
Mailing Address - Country:US
Mailing Address - Phone:253-596-3300
Mailing Address - Fax:
Practice Address - Street 1:209 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4265
Practice Address - Country:US
Practice Address - Phone:253-596-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88247208000000X
WAMD60265218208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268285100Medicaid
FL81795XMedicare PIN