Provider Demographics
NPI:1548226665
Name:ALLEN, JEFFREY J (MACP)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:J
Last Name:ALLEN
Suffix:
Gender:M
Credentials:MACP
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 659
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:VT
Mailing Address - Zip Code:05601-0659
Mailing Address - Country:US
Mailing Address - Phone:802-223-4342
Mailing Address - Fax:802-223-7311
Practice Address - Street 1:133 ELM ST.
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602-3172
Practice Address - Country:US
Practice Address - Phone:802-223-4342
Practice Address - Fax:802-223-7311
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTALLE 062 9965OtherBLUE CROSS BLUE SHIELD
VTOVN1676OtherVERMONT MEDICAID