Provider Demographics
NPI:1396406575
Name:ALLEN, JAILAH LEANNE
Entity Type:Individual
Prefix:
First Name:JAILAH
Middle Name:LEANNE
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 1:443 SE BROWN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-6083
Mailing Address - Country:US
Mailing Address - Phone:386-243-1534
Mailing Address - Fax:
Practice Address - Street 1:4907 NW 43RD ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-2006
Practice Address - Country:US
Practice Address - Phone:352-372-0047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-198811106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician