Provider Demographics
NPI:1235368259
Name:ALLEY, JENNYL
Entity Type:Individual
Prefix:
First Name:JENNYL
Middle Name:
Last Name:ALLEY
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 1:4908 SPRING MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-9001
Mailing Address - Country:US
Mailing Address - Phone:704-996-5179
Mailing Address - Fax:
Practice Address - Street 1:4908 SPRING MEADOW LN
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-9001
Practice Address - Country:US
Practice Address - Phone:704-996-5179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-12
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
NC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC251S00000XMedicaid