Provider Demographics
NPI:1609454453
Name:COLLINS, JESSICA LB
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LB
Last Name:COLLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 ASCOT DR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3400
Mailing Address - Country:US
Mailing Address - Phone:916-787-1100
Mailing Address - Fax:
Practice Address - Street 1:2185 BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95966-5312
Practice Address - Country:US
Practice Address - Phone:530-538-8221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician