Healthcare Provider Details

I. General information

NPI: 1407772601
Provider Name (Legal Business Name): JENNIFER KOLLASCH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10245 CENTURION PKWY N STE 250
JACKSONVILLE FL
32256-0561
US

IV. Provider business mailing address

3450 PEORIA RD
ORANGE PARK FL
32065-7625
US

V. Phone/Fax

Practice location:
  • Phone: 904-674-3521
  • Fax:
Mailing address:
  • Phone: 904-449-2211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH29360
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: