Provider Demographics
NPI:1548227424
Name:ALLEN, JACKIE L (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:L
Last Name:ALLEN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 DOLAN DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-5201
Mailing Address - Country:US
Mailing Address - Phone:912-657-1455
Mailing Address - Fax:
Practice Address - Street 1:325 W MONTGOMERY XRD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3309
Practice Address - Country:US
Practice Address - Phone:912-921-2001
Practice Address - Fax:
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
GAR069517363LA2200X, 163WP2201X, 163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Not Answered163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
Not Answered163WA2000XNursing Service ProvidersRegistered NurseAdministrator