Provider Demographics
NPI:1003341686
Name:COLLINS, KRYSTAL JACQUELLE
Entity Type:Individual
Prefix:MS
First Name:KRYSTAL
Middle Name:JACQUELLE
Last Name:COLLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 SASSAFRAS ST
Mailing Address - Street 2:
Mailing Address - City:AMITE
Mailing Address - State:LA
Mailing Address - Zip Code:70422-3425
Mailing Address - Country:US
Mailing Address - Phone:225-644-8565
Mailing Address - Fax:225-644-6261
Practice Address - Street 1:104 SASSAFRAS ST
Practice Address - Street 2:
Practice Address - City:AMITE
Practice Address - State:LA
Practice Address - Zip Code:70422-3425
Practice Address - Country:US
Practice Address - Phone:225-644-8565
Practice Address - Fax:225-644-6261
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health