Provider Demographics
NPI:1669755278
Name:COLLARD, JENNIFER NICOLE (LMT 16076)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:NICOLE
Last Name:COLLARD
Suffix:
Gender:F
Credentials:LMT 16076
Other - Prefix:MISS
Other - First Name:JENNIFLER
Other - Middle Name:NICOLE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:730 SE OAK ST STE K
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4245
Mailing Address - Country:US
Mailing Address - Phone:503-430-1057
Mailing Address - Fax:503-430-1085
Practice Address - Street 1:730 SE OAK ST STE K
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4245
Practice Address - Country:US
Practice Address - Phone:503-430-1057
Practice Address - Fax:503-430-1085
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLMT 16076171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor