Provider Demographics
NPI:1528321643
Name:ALLEN, JESSIE ELIZABETH (DO)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:ELIZABETH
Last Name:ALLEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JESSIE
Other - Middle Name:ELIZABETH
Other - Last Name:DEVILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 73720
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-3720
Mailing Address - Country:US
Mailing Address - Phone:907-459-3500
Mailing Address - Fax:907-459-3526
Practice Address - Street 1:PEDS DEPT - 14 MEDICAL PARK
Practice Address - Street 2:SUITE 400
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-434-6155
Practice Address - Fax:803-434-6979
Is Sole Proprietor?:No
Enumeration Date:2012-06-22
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK155151208000000X
SCLL1568208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics