Provider Demographics
NPI:1548724040
Name:KOLLORE, JEMILL HESTER (TRAINEE STATUS)
Entity type:Individual
Prefix:
First Name:JEMILL
Middle Name:HESTER
Last Name:KOLLORE
Suffix:
Gender:F
Credentials:TRAINEE STATUS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30007 BUSINESS CENTER DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE HALL
Mailing Address - State:MD
Mailing Address - Zip Code:20622-3101
Mailing Address - Country:US
Mailing Address - Phone:301-997-1300
Mailing Address - Fax:301-290-0280
Practice Address - Street 1:30007 BUSINESS CENTER DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE HALL
Practice Address - State:MD
Practice Address - Zip Code:20622-3101
Practice Address - Country:US
Practice Address - Phone:301-997-1300
Practice Address - Fax:301-290-0280
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDADT-072101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)