Provider Demographics
NPI:1619084118
Name:ALLEN, JENNIFER LEE (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3124 N SWAN RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-1227
Mailing Address - Country:US
Mailing Address - Phone:520-325-4002
Mailing Address - Fax:520-325-4227
Practice Address - Street 1:3124 N SWAN RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-1227
Practice Address - Country:US
Practice Address - Phone:520-325-4002
Practice Address - Fax:520-325-4227
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5251225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ630683Medicaid
AZ5228060001Medicare NSC
AZ630683Medicaid