Provider Demographics
NPI:1740809151
Name:ALLEN, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
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:PO BOX 887
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:NM
Mailing Address - Zip Code:87416-0887
Mailing Address - Country:US
Mailing Address - Phone:505-215-1219
Mailing Address - Fax:
Practice Address - Street 1:#786 CR 6100
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:NM
Practice Address - Zip Code:87416
Practice Address - Country:US
Practice Address - Phone:505-215-1219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician