Provider Demographics
NPI:1689272874
Name:ALLEN, JACOB OLIVER
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:OLIVER
Last Name:ALLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3506 FRONTIER DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-6636
Mailing Address - Country:US
Mailing Address - Phone:636-544-2388
Mailing Address - Fax:636-544-2388
Practice Address - Street 1:3506 FRONTIER DR
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-6636
Practice Address - Country:US
Practice Address - Phone:636-544-2388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-11
Last Update Date:2020-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO390200000X390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program