Basic Information
| Provider Information | |||||||||
| NPI: | 1871722017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | RUTH | ||||||||
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| OtherLastName: | ALLEN | ||||||||
| OtherFirstName: | JACQUELYN | ||||||||
| OtherMiddleName: | RUTH | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 225 KILT CT | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952101923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107122162 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3800 COOLIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946023311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104855334 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2009 | ||||||||
| LastUpdateDate: | 01/20/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 81620 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.