Healthcare Provider Details

I. General information

NPI: 1467785816
Provider Name (Legal Business Name): JENNIE COLLADO LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIE MIMMS

II. Dates (important events)

Enumeration Date: 09/16/2009
Last Update Date: 03/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17840 CUMBERLAND RD
NOBLESVILLE IN
46060-5409
US

IV. Provider business mailing address

9615 E 148TH ST SUITE 1
NOBLESVILLE IN
46060-4360
US

V. Phone/Fax

Practice location:
  • Phone: 317-773-6864
  • Fax: 317-674-0059
Mailing address:
  • Phone: 317-587-0533
  • Fax: 317-674-0059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35001745A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: