Provider Demographics
NPI:1124290028
Name:COLLINS, JESSE F JR (PA-C)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:F
Last Name:COLLINS
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5015 PARKGLEN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-1014
Mailing Address - Country:US
Mailing Address - Phone:323-291-1534
Mailing Address - Fax:
Practice Address - Street 1:6221 WILSHIRE BLVD
Practice Address - Street 2:SUITE 416
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5201
Practice Address - Country:US
Practice Address - Phone:323-938-9999
Practice Address - Fax:323-456-0880
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19628363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant