Healthcare Provider Details

I. General information

NPI: 1952023301
Provider Name (Legal Business Name): JENNIFER COLLINS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 09/13/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 S MAIN STREET
THREE FORKS MT
59752
US

IV. Provider business mailing address

207 SHOW PL APT A
BELGRADE MT
59714-3438
US

V. Phone/Fax

Practice location:
  • Phone: 406-285-0626
  • Fax:
Mailing address:
  • Phone: 406-490-6780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number24509
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: