Provider Demographics
NPI:1821443524
Name:COLLINS, JESSICA (DO)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:COLLINS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 E GATEWAY DR STE 103
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-4611
Mailing Address - Country:US
Mailing Address - Phone:435-315-3147
Mailing Address - Fax:435-355-3737
Practice Address - Street 1:322 E GATEWAY DR STE 103
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-4611
Practice Address - Country:US
Practice Address - Phone:435-315-3147
Practice Address - Fax:435-355-3737
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-01
Last Update Date:2022-05-25
Deactivation Date:2021-09-09
Deactivation Code:
Reactivation Date:2021-09-14
Provider Licenses
StateLicense IDTaxonomies
MN70219207N00000X
UT10929348-1204207NS0135X, 207ND0101X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty