Provider Demographics
NPI:1306380738
Name:COLLINS, JENICE (INDEPENDENT SERVICE)
Entity Type:Individual
Prefix:
First Name:JENICE
Middle Name:
Last Name:COLLINS
Suffix:
Gender:F
Credentials:INDEPENDENT SERVICE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 EDDY RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44108-1754
Mailing Address - Country:US
Mailing Address - Phone:216-848-9115
Mailing Address - Fax:
Practice Address - Street 1:423 EDDY RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44108-1754
Practice Address - Country:US
Practice Address - Phone:216-848-9115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-04
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0405697Medicaid
OH0405697Medicaid