Provider Demographics
NPI:1972156321
Name:ALLEN, JESSICA D
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:D
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 VALLEY OAK CT
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1372
Mailing Address - Country:US
Mailing Address - Phone:937-829-3675
Mailing Address - Fax:
Practice Address - Street 1:521 VALLEY OAK CT
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45415-1372
Practice Address - Country:US
Practice Address - Phone:937-829-3675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401326911211376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH401326911211Medicaid