Provider Demographics
NPI:1396174231
Name:ALLEN, JACQUELYN PORTER
Entity type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:PORTER
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 1:101 S FIRCROFT ST
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-2004
Mailing Address - Country:US
Mailing Address - Phone:818-384-8339
Mailing Address - Fax:
Practice Address - Street 1:5130 PECOS ROAD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120
Practice Address - Country:US
Practice Address - Phone:818-384-8339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst