Basic Information
| Provider Information | |||||||||
| NPI: | 1841223567 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLISSON | ||||||||
| FirstName: | JENNY-VIVA | ||||||||
| MiddleName: | EDEN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3901 23RD ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941143302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158304744 | ||||||||
| FaxNumber: | 4152910489 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 23RD ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941143302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158304744 | ||||||||
| FaxNumber: | 4152910489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 12/17/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A84835 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | BG8627943 | 01 | CA | DEA | OTHER |