Provider Demographics
NPI:1295203578
Name:COLLINS, JEROD ANTHONY
Entity Type:Individual
Prefix:
First Name:JEROD
Middle Name:ANTHONY
Last Name:COLLINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2278 LOS PADRES BLVD APT 4
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95050-6821
Mailing Address - Country:US
Mailing Address - Phone:408-401-8317
Mailing Address - Fax:
Practice Address - Street 1:1401 PARKMOOR AVE STE 208
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-3407
Practice Address - Country:US
Practice Address - Phone:408-885-0805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst