Provider Demographics
NPI:1457107906
Name:ALLEN-JAMISON, ILEOLA MIRIAM
Entity type:Individual
Prefix:
First Name:ILEOLA
Middle Name:MIRIAM
Last Name:ALLEN-JAMISON
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 1:109-119 BROAD ST #308
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104
Mailing Address - Country:US
Mailing Address - Phone:973-841-3961
Mailing Address - Fax:
Practice Address - Street 1:109-119 BROAD ST #308
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104
Practice Address - Country:US
Practice Address - Phone:973-841-3961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-25
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DP00585400126800000X
261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No126800000XDental ProvidersDental Assistant