Provider Demographics
NPI:1144591777
Name:ALLEN, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:915 PEACH LN
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-7091
Mailing Address - Country:US
Mailing Address - Phone:817-995-5403
Mailing Address - Fax:206-350-1562
Practice Address - Street 1:915 PEACH LN
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-7091
Practice Address - Country:US
Practice Address - Phone:817-995-5403
Practice Address - Fax:206-350-1562
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF7989207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85G698Medicare Oscar/Certification