Healthcare Provider Details

I. General information

NPI: 1558518472
Provider Name (Legal Business Name): JESSICA MICHELLE COLLINS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2008
Last Update Date: 04/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 HARTFORD RD E
FORT GAINES GA
39851-3638
US

IV. Provider business mailing address

PO BOX 489
CUTHBERT GA
39840-0489
US

V. Phone/Fax

Practice location:
  • Phone: 229-768-2633
  • Fax: 229-768-2263
Mailing address:
  • Phone: 229-768-2633
  • Fax: 229-768-2263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN162833
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: