Provider Demographics
NPI:1083326862
Name:COLLAZO, JESSENIA (RN)
Entity Type:Individual
Prefix:
First Name:JESSENIA
Middle Name:
Last Name:COLLAZO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5071 LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-4195
Mailing Address - Country:US
Mailing Address - Phone:219-743-5359
Mailing Address - Fax:
Practice Address - Street 1:2901 W 37TH AVE
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-1727
Practice Address - Country:US
Practice Address - Phone:219-942-2179
Practice Address - Fax:219-942-7781
Is Sole Proprietor?:No
Enumeration Date:2022-12-23
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28268531A163WR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0400XNursing Service ProvidersRegistered NurseRehabilitation