Provider Demographics
NPI:1629300942
Name:ALLEN, JACQUELYN LAVETTE (MOTR/L, CPAM)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:LAVETTE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MOTR/L, CPAM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17366 WAUSAU AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-3359
Mailing Address - Country:US
Mailing Address - Phone:708-705-2670
Mailing Address - Fax:
Practice Address - Street 1:17366 WAUSAU AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-3359
Practice Address - Country:US
Practice Address - Phone:708-705-2670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-11
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056007568174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist