Provider Demographics
NPI:1144232885
Name:MELVIN, JEFF NEAL (PHD)
Entity type:Individual
Prefix:DR
First Name:JEFF
Middle Name:NEAL
Last Name:MELVIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13670 METROPOLIS AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4346
Mailing Address - Country:US
Mailing Address - Phone:239-910-1534
Mailing Address - Fax:
Practice Address - Street 1:13670 METROPOLIS AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4346
Practice Address - Country:US
Practice Address - Phone:239-910-1534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2014-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9023103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47077604000Medicaid
NE10025243600Medicaid