Provider Demographics
NPI:1598935298
Name:ALLEN, JEANNE ELLEN (MA)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:ELLEN
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 SIALIA WAY
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25404
Mailing Address - Country:US
Mailing Address - Phone:304-274-4091
Mailing Address - Fax:
Practice Address - Street 1:110 MORDINGTON AVENUE
Practice Address - Street 2:JEFFERSON COUNTY BOARD OF EDUCATION
Practice Address - City:CHARLESTOWN
Practice Address - State:WV
Practice Address - Zip Code:25414
Practice Address - Country:US
Practice Address - Phone:304-725-9741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10013103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0165627000Medicaid