Healthcare Provider Details

I. General information

NPI: 1497670350
Provider Name (Legal Business Name): JACQUELINE COLVARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 S LUDLOW ST
DAYTON OH
45402-1813
US

IV. Provider business mailing address

721 TORRINGTON PL
DAYTON OH
45406-4441
US

V. Phone/Fax

Practice location:
  • Phone: 937-542-6610
  • Fax:
Mailing address:
  • Phone: 937-276-8411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: