Provider Demographics
NPI:1497057483
Name:COLLINS, JEFFERY S (MA)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:S
Last Name:COLLINS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 W MAIN ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1650
Mailing Address - Country:US
Mailing Address - Phone:304-842-7007
Mailing Address - Fax:304-842-7099
Practice Address - Street 1:917 W MAIN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1650
Practice Address - Country:US
Practice Address - Phone:304-842-7007
Practice Address - Fax:304-842-7099
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV909103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist