Provider Demographics
NPI:1194393090
Name:ALLEN, ALEAH J
Entity Type:Individual
Prefix:
First Name:ALEAH
Middle Name:J
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 1:4780 I 55 N STE 105
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5542
Mailing Address - Country:US
Mailing Address - Phone:601-956-4816
Mailing Address - Fax:601-956-4817
Practice Address - Street 1:4780 I 55 N STE 105
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5542
Practice Address - Country:US
Practice Address - Phone:601-956-4816
Practice Address - Fax:601-956-4817
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health