Provider Demographics
NPI:1922729508
Name:COLLIER, JERYN
Entity Type:Individual
Prefix:
First Name:JERYN
Middle Name:
Last Name:COLLIER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 S STONEY POINT ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67209-3524
Mailing Address - Country:US
Mailing Address - Phone:229-630-1798
Mailing Address - Fax:
Practice Address - Street 1:6700 W CENTRAL AVE STE 106
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-6302
Practice Address - Country:US
Practice Address - Phone:316-945-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLMFT03422-T101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor