Provider Demographics
NPI:1134360944
Name:COLLINS, JENNIFER LEE ANN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE ANN
Last Name:COLLINS
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 DITMARS BLVD APT 3B
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-3921
Mailing Address - Country:US
Mailing Address - Phone:510-857-4762
Mailing Address - Fax:
Practice Address - Street 1:82-68 164TH STREET
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432
Practice Address - Country:US
Practice Address - Phone:718-883-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013144-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant