Provider Demographics
NPI:1043820012
Name:COLLI, JACQUELINE AMANDA (OTR/L)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:AMANDA
Last Name:COLLI
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 BUSINESS CENTER DR STE 127
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3434
Mailing Address - Country:US
Mailing Address - Phone:909-890-9030
Mailing Address - Fax:909-890-4393
Practice Address - Street 1:3400 CENTRAL AVE STE 145
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2161
Practice Address - Country:US
Practice Address - Phone:951-297-3399
Practice Address - Fax:909-890-4393
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21482225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty