Provider Demographics
NPI:1043820012
Name:COLLI, JACQUELINE AMANDA (OTR/L)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:AMANDA
Last Name:COLLI
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 FOSTER RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-2247
Mailing Address - Country:US
Mailing Address - Phone:347-668-6367
Mailing Address - Fax:
Practice Address - Street 1:1868 HOOPER AVE
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-8175
Practice Address - Country:US
Practice Address - Phone:347-668-6367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024139-01225X00000X
CA21482225X00000X
NJ46TR00932100225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty