Provider Demographics
NPI:1225324247
Name:ALLEN, JORDAN (MS, LAC)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:MS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 CABLE ST
Mailing Address - Street 2:SUITE 'B'
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-3141
Mailing Address - Country:US
Mailing Address - Phone:619-243-5109
Mailing Address - Fax:619-243-5113
Practice Address - Street 1:1804 CABLE ST
Practice Address - Street 2:SUITE 'B'
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92107-3141
Practice Address - Country:US
Practice Address - Phone:619-243-5109
Practice Address - Fax:619-243-5113
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-28
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12322171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist