Provider Demographics
NPI:1255172391
Name:COLLINS, JQUAM SAREITTA
Entity type:Individual
Prefix:
First Name:JQUAM
Middle Name:SAREITTA
Last Name:COLLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2786 SHAFFER AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45211-7113
Mailing Address - Country:US
Mailing Address - Phone:513-371-0772
Mailing Address - Fax:
Practice Address - Street 1:2786 SHAFFER AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-7113
Practice Address - Country:US
Practice Address - Phone:513-371-0772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH188128101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)