Provider Demographics
NPI:1245258383
Name:WALLEN, JANE BURGESS (LCSW)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:BURGESS
Last Name:WALLEN
Suffix:
Gender:F
Credentials:LCSW
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 790
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-0790
Mailing Address - Country:US
Mailing Address - Phone:606-329-8588
Mailing Address - Fax:606-329-8195
Practice Address - Street 1:60 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-9644
Practice Address - Country:US
Practice Address - Phone:606-638-4332
Practice Address - Fax:606-638-4394
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-12631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
001723358OtherMSBCBS
KY7100282900Medicaid
610661987OtherCORPHEALTH
1175490OtherCHA
KY000000207306OtherANTHEM BCBS
11491126OtherCAQH #
279403OtherMANAGED HEALTH
KY7100282900Medicaid