Provider Demographics
NPI:1760972806
Name:COLLEY, JIMMY DALE JR (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:DALE
Last Name:COLLEY
Suffix:JR
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9179 FRANCES RD
Mailing Address - Street 2:
Mailing Address - City:OTISVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48463-9411
Mailing Address - Country:US
Mailing Address - Phone:810-210-2077
Mailing Address - Fax:
Practice Address - Street 1:9179 FRANCES RD
Practice Address - Street 2:
Practice Address - City:OTISVILLE
Practice Address - State:MI
Practice Address - Zip Code:48463-9411
Practice Address - Country:US
Practice Address - Phone:810-210-2077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201005312225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist