Provider Demographics
NPI:1871722017
Name:ALLEN, JACQUELYN RUTH
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:RUTH
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:RUTH
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:225 KILT CT
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-1923
Mailing Address - Country:US
Mailing Address - Phone:510-712-2162
Mailing Address - Fax:
Practice Address - Street 1:3800 COOLIDGE AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-3311
Practice Address - Country:US
Practice Address - Phone:510-485-5334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-09
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81620106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist