Provider Demographics
NPI:1073820015
Name:COLLOM, JENNIFER ANN (COTA/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:COLLOM
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 NE MARGO CT
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66617-4532
Mailing Address - Country:US
Mailing Address - Phone:785-286-1426
Mailing Address - Fax:785-271-9430
Practice Address - Street 1:4712 SW 6TH AVE
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-2272
Practice Address - Country:US
Practice Address - Phone:785-271-9430
Practice Address - Fax:785-271-9430
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-00166224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant