Basic Information
| Provider Information | |||||||||
| NPI: | 1164518510 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | BSW LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5707 N 22ND STREET | ||||||||
| Address2: | MENTAL HEALTH CARE INC | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132722878 | ||||||||
| FaxNumber: | 8132723766 | ||||||||
| Practice Location | |||||||||
| Address1: | 5707 N 22ND STREET | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132722878 | ||||||||
| FaxNumber: | 8132723766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 10/13/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 164W00000X | PN 5182298 | FL | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | 766972100 | 05 | FL | MEDICAID |