Provider Demographics
NPI:1730578121
Name:ALLEN, JACQUELINE D (APRN)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:D
Last Name:ALLEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 959
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41702-0959
Mailing Address - Country:US
Mailing Address - Phone:606-436-0711
Mailing Address - Fax:606-435-1322
Practice Address - Street 1:210 BLACK GOLD BLVD
Practice Address - Street 2:STE 106
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-2620
Practice Address - Country:US
Practice Address - Phone:606-436-0711
Practice Address - Fax:606-435-1322
Is Sole Proprietor?:No
Enumeration Date:2015-01-22
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009147363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3009147OtherLICENSE