Healthcare Provider Details

I. General information

NPI: 1003720475
Provider Name (Legal Business Name): JAHMYA E COLLYMORE-KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

284 CAMBO ST
BROCKTON MA
02301-6372
US

IV. Provider business mailing address

284 CAMBO ST
BROCKTON MA
02301-6372
US

V. Phone/Fax

Practice location:
  • Phone: 617-318-7611
  • Fax: 617-318-7611
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: