Provider Demographics
NPI:1083697221
Name:ALLEN, JON MICHAEL (OTRL)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:MICHAEL
Last Name:ALLEN
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:748 CHESTNUT AVE
Mailing Address - Street 2:APT. 1-C
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-1645
Mailing Address - Country:US
Mailing Address - Phone:606-224-6915
Mailing Address - Fax:
Practice Address - Street 1:748 CHESTNUT AVE
Practice Address - Street 2:APT 1-C
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-1645
Practice Address - Country:US
Practice Address - Phone:606-224-6915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR1749225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist