Provider Demographics
NPI:1730472804
Name:ALLEN, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
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 1:448 LAKESHORE PKWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-4264
Mailing Address - Country:US
Mailing Address - Phone:803-323-0068
Mailing Address - Fax:
Practice Address - Street 1:448 LAKESHORE PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-4264
Practice Address - Country:US
Practice Address - Phone:803-323-0068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-24
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health