Provider Demographics
NPI:1356947295
Name:COLLABORATIVE PAIN MANAGEMENT, PLLC
Entity type:Organization
Organization Name:COLLABORATIVE PAIN MANAGEMENT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JACQUES
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:703-261-6758
Mailing Address - Street 1:10400 EATON PL STE 312
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2208
Mailing Address - Country:US
Mailing Address - Phone:703-261-6758
Mailing Address - Fax:703-995-4860
Practice Address - Street 1:10400 EATON PL STE 312
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2208
Practice Address - Country:US
Practice Address - Phone:703-261-6758
Practice Address - Fax:703-995-4860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Single Specialty