Provider Demographics
NPI:1548789217
Name:COLLINS, JANISICA YASMEAN (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JANISICA
Middle Name:YASMEAN
Last Name:COLLINS
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4578 BEXLEY WAY
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-5524
Mailing Address - Country:US
Mailing Address - Phone:404-317-6947
Mailing Address - Fax:
Practice Address - Street 1:718 MAGNOLIA DRIVE
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35487-0001
Practice Address - Country:US
Practice Address - Phone:404-317-6947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GAAT0037502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program