Provider Demographics
NPI:1033683743
Name:ALLEN, JACQUELINE (LAC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:LEADVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80461-3558
Mailing Address - Country:US
Mailing Address - Phone:719-239-1452
Mailing Address - Fax:
Practice Address - Street 1:518 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:LEADVILLE
Practice Address - State:CO
Practice Address - Zip Code:80461-3558
Practice Address - Country:US
Practice Address - Phone:719-239-1452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU.0002461171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist