Provider Demographics
NPI:1578387213
Name:COLLIER, JENNIFER DIANA (LAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DIANA
Last Name:COLLIER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3133 E ROCK WREN RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-8736
Mailing Address - Country:US
Mailing Address - Phone:847-707-0112
Mailing Address - Fax:
Practice Address - Street 1:4435 E CHANDLER BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-7651
Practice Address - Country:US
Practice Address - Phone:480-724-9910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-20067101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health