Provider Demographics
NPI:1093242075
Name:ALLEN, JAQUESHIA LAFAYE
Entity Type:Individual
Prefix:
First Name:JAQUESHIA
Middle Name:LAFAYE
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 1:3708 CAMELOT DR SE APT 2B
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6023
Mailing Address - Country:US
Mailing Address - Phone:810-336-4629
Mailing Address - Fax:
Practice Address - Street 1:3708 CAMELOT DR SE APT 2B
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6023
Practice Address - Country:US
Practice Address - Phone:810-336-4629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011138101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical