Provider Demographics
NPI:1215481114
Name:COLLINS, JACQUELYN HEATHER (PT, DPT)
Entity type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:HEATHER
Last Name:COLLINS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35-02 VAN DUREN AVE
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-5008
Mailing Address - Country:US
Mailing Address - Phone:201-693-2742
Mailing Address - Fax:
Practice Address - Street 1:201 PLEASANT HILL RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:NJ
Practice Address - Zip Code:07930-2141
Practice Address - Country:US
Practice Address - Phone:201-693-2742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01597300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist