Provider Demographics
NPI:1205239860
Name:COLLINS, JENNIFER J (APRN)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:J
Last Name:COLLINS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:J
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:KY
Mailing Address - Zip Code:42450-0037
Mailing Address - Country:US
Mailing Address - Phone:270-667-7017
Mailing Address - Fax:270-667-9065
Practice Address - Street 1:215 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:KY
Practice Address - Zip Code:42450-1261
Practice Address - Country:US
Practice Address - Phone:270-667-7017
Practice Address - Fax:270-667-9065
Is Sole Proprietor?:No
Enumeration Date:2014-09-26
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008979363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100313240Medicaid
KYK162740Medicare PIN