Provider Demographics
NPI:1851854509
Name:COLLAZO, JACQUELINE (LMHC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:COLLAZO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1473 WATSON AVE APT 1R
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10472-5340
Mailing Address - Country:US
Mailing Address - Phone:914-646-6638
Mailing Address - Fax:
Practice Address - Street 1:1473 WATSON AVE APT 1R
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10472-5340
Practice Address - Country:US
Practice Address - Phone:914-646-6638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health