Provider Demographics
NPI:1679080634
Name:COLLINS, JENNIFER (MED)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:COLLINS
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 BONNIEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-2333
Mailing Address - Country:US
Mailing Address - Phone:216-789-9370
Mailing Address - Fax:
Practice Address - Street 1:24865 DETROIT RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-2512
Practice Address - Country:US
Practice Address - Phone:440-250-8800
Practice Address - Fax:440-641-1170
Is Sole Proprietor?:No
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3205181171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator