=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679778237
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICAH S. COLLINS M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2007
-----------------------------------------------------
Last Update Date | 05/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 SPORTS MEDICINE DRIVE SUITE 100
-----------------------------------------------------
City | FISHERSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-221-7180
-----------------------------------------------------
Fax | 540-221-7181
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 388
-----------------------------------------------------
City | FISHERSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22939-0388
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | 0116019541
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | 0101250350
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------