=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710567540
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSE COLLIER APRN FNP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2021
-----------------------------------------------------
Last Update Date | 09/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1919 S SHILOH RD STE 400
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75042-8211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-320-1267
-----------------------------------------------------
Fax | 469-320-1268
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O BOX 29650, DEPT # 880579
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85038-9650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-616-0016
-----------------------------------------------------
Fax | 480-626-2690
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1034171
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------