Healthcare Provider Details

I. General information

NPI: 1710567540
Provider Name (Legal Business Name): JESSE COLLIER APRN FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 S SHILOH RD STE 400
GARLAND TX
75042-8211
US

IV. Provider business mailing address

P.O BOX 29650, DEPT # 880579
PHOENIX AZ
85038-9650
US

V. Phone/Fax

Practice location:
  • Phone: 469-320-1267
  • Fax: 469-320-1268
Mailing address:
  • Phone: 480-616-0016
  • Fax: 480-626-2690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1034171
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: