Provider Demographics
NPI:1275146532
Name:ALLEN, JACQUELINE RENEE' (MA, LISAC, CSAT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RENEE'
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MA, LISAC, CSAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14300 N NORTHSIGHT BLVD STE 109
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-3673
Mailing Address - Country:US
Mailing Address - Phone:217-778-6442
Mailing Address - Fax:
Practice Address - Street 1:14300 N NORTHSIGHT BLVD STE 109
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-3673
Practice Address - Country:US
Practice Address - Phone:217-778-6442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-15051101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)