Healthcare Provider Details

I. General information

NPI: 1124290028
Provider Name (Legal Business Name): JESSE F COLLINS JR. P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 06/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6221 WILSHIRE BLVD SUITE 416
LOS ANGELES CA
90048-5201
US

IV. Provider business mailing address

5015 PARKGLEN AVE
LOS ANGELES CA
90043-1014
US

V. Phone/Fax

Practice location:
  • Phone: 323-938-9999
  • Fax: 323-456-0880
Mailing address:
  • Phone: 323-291-1534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA19628
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: