Provider Demographics
NPI:1508254277
Name:ALLEN, JESSICA (RDH)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3000C
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-0553
Mailing Address - Country:US
Mailing Address - Phone:188-846-8002
Mailing Address - Fax:
Practice Address - Street 1:97829 SHOPPING CENTER AVE
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9135
Practice Address - Country:US
Practice Address - Phone:888-468-0022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD5595124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist