Provider Demographics
NPI:1588690374
Name:ALLEN, JERILYN S (MD)
Entity type:Individual
Prefix:DR
First Name:JERILYN
Middle Name:S
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 WATSON ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2122
Mailing Address - Country:US
Mailing Address - Phone:860-456-0287
Mailing Address - Fax:860-456-3532
Practice Address - Street 1:36 WATSON ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2122
Practice Address - Country:US
Practice Address - Phone:860-456-0287
Practice Address - Fax:860-456-3532
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034032207YX0602X, 207YX0905X, 207Y00000X, 207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic AllergyGroup - Single Specialty
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001340322Medicaid