Healthcare Provider Details

I. General information

NPI: 1578092490
Provider Name (Legal Business Name): ZACHARY D'ANDRE ALLEN SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2017
Last Update Date: 06/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6867 SOUTHPOINT DR N
JACKSONVILLE FL
32216-8043
US

IV. Provider business mailing address

6867 SOUTHPOINT DR N
JACKSONVILLE FL
32216-8043
US

V. Phone/Fax

Practice location:
  • Phone: 904-619-6071
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: