Provider Demographics
NPI:1558020834
Name:ALLEN, JACEY
Entity Type:Individual
Prefix:
First Name:JACEY
Middle Name:
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 1:106 BALL ST APT B
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3702
Mailing Address - Country:US
Mailing Address - Phone:304-573-0490
Mailing Address - Fax:
Practice Address - Street 1:130 GEORGE ST STE J
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2648
Practice Address - Country:US
Practice Address - Phone:304-929-2670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant