Provider Demographics
NPI:1720515489
Name:COLON, JALISSA (LPN)
Entity Type:Individual
Prefix:
First Name:JALISSA
Middle Name:
Last Name:COLON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 KINGSBERRY DR
Mailing Address - Street 2:APT B
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-2240
Mailing Address - Country:US
Mailing Address - Phone:585-820-8894
Mailing Address - Fax:
Practice Address - Street 1:111 KINGSBERRY DR
Practice Address - Street 2:APT B
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-2240
Practice Address - Country:US
Practice Address - Phone:585-820-8894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303400164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse