Healthcare Provider Details

I. General information

NPI: 1912864570
Provider Name (Legal Business Name): DR. JORDAN COLLINS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 ESTILL DR
SPRINGFIELD IL
62707-8444
US

IV. Provider business mailing address

2726 W LUNT AVE APT 3E
CHICAGO IL
60645-3039
US

V. Phone/Fax

Practice location:
  • Phone: 217-801-8314
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071022739
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: