Provider Demographics
NPI:1083112809
Name:KOLLER, JAMIE
Entity Type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:
Last Name:KOLLER
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 1:507 SEAVIEW DR
Mailing Address - Street 2:
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932-9269
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 S WATER ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-4942
Practice Address - Country:US
Practice Address - Phone:252-333-4569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-26
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA13569101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health