Provider Demographics
NPI:1922720887
Name:JERRICK, COLLETTA LATOYA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:COLLETTA
Middle Name:LATOYA
Last Name:JERRICK
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1548 E FORKS RD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-3144
Mailing Address - Country:US
Mailing Address - Phone:631-308-7658
Mailing Address - Fax:
Practice Address - Street 1:1548 E FORKS RD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-3144
Practice Address - Country:US
Practice Address - Phone:631-308-7658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF403813-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF403813-01OtherNEW YORK STATE OFFICE OF THE PROFESSIONS