Healthcare Provider Details

I. General information

NPI: 1225862204
Provider Name (Legal Business Name): JESSICA COLLINS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2024
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3830 HIGHWAY 15 S
JACKSON KY
41339-8675
US

IV. Provider business mailing address

115 ROCKWOOD LN
HAZARD KY
41701-9415
US

V. Phone/Fax

Practice location:
  • Phone: 800-575-7223
  • Fax: 606-436-5797
Mailing address:
  • Phone: 800-575-7223
  • Fax: 606-436-5797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number259584
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: