Provider Demographics
NPI:1780948257
Name:KOLLAROS, JESSICA ANN MARIE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN MARIE
Last Name:KOLLAROS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14706 RICHARD SIMPSON LN
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-6214
Mailing Address - Country:US
Mailing Address - Phone:575-496-2904
Mailing Address - Fax:
Practice Address - Street 1:11350 RANDOM HILLS RD STE 885
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6044
Practice Address - Country:US
Practice Address - Phone:703-342-4690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-29
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202007156235Z00000X
DCSLP001501235Z00000X
NMC-5124235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist