Provider Demographics
NPI:1720420193
Name:COLLINS, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:COLLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6570
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85385-6570
Mailing Address - Country:US
Mailing Address - Phone:623-398-8072
Mailing Address - Fax:623-398-8235
Practice Address - Street 1:5977 E GRANT RD
Practice Address - Street 2:SUITE 101
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2341
Practice Address - Country:US
Practice Address - Phone:520-822-8640
Practice Address - Fax:520-822-8641
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12436-242251X0800X
AZ10344225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic