1659755429 NPI number — MRS. JAZMINE DAVIS COLLINS FNP-C

Table of content: MRS. JAZMINE DAVIS COLLINS FNP-C (NPI 1659755429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659755429 NPI number — MRS. JAZMINE DAVIS COLLINS FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLLINS
Provider First Name:
JAZMINE
Provider Middle Name:
DAVIS
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659755429
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1040 RIVER OAKS DR
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
FLOWOOD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39232-9530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-326-2599
Provider Business Mailing Address Fax Number:
601-933-0852

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 SE LOOP 820
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76140-1013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-922-8182
Provider Business Practice Location Address Fax Number:
817-922-8182
Provider Enumeration Date:
07/12/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  AP134339 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 113706200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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