Provider Demographics
NPI:1275822991
Name:ALLEN, JESSICA M (COTA/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:ALLEN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 LINDEN ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-1703
Mailing Address - Country:US
Mailing Address - Phone:231-510-2391
Mailing Address - Fax:
Practice Address - Street 1:419 LINDEN ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-1703
Practice Address - Country:US
Practice Address - Phone:231-510-2391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202007371314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
U1909984804OtherCIGNA