Basic Information
| Provider Information | |||||||||
| NPI: | 1184707929 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLF | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | JAKSA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JAKSA | ||||||||
| OtherFirstName: | CHRISTINA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 32417 HEARTHSTONE RD | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483343473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5869446379 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 31000 TELEGRAPH RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | BINGHAM FARMS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480254360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485944991 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 04/01/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| ParentOrganizationLBN: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301012781 | MI | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 6301014641 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.