Provider Demographics
NPI:1841313681
Name:ALLEN, JACKIE M (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:M
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MRS
Other - First Name:JACQUELINE
Other - Middle Name:M
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:528 CRAIG LANE
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324
Mailing Address - Country:US
Mailing Address - Phone:859-489-9310
Mailing Address - Fax:502-863-4426
Practice Address - Street 1:528 CRAIG LANE
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324
Practice Address - Country:US
Practice Address - Phone:859-489-9310
Practice Address - Fax:502-863-4426
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0951235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist