| Doctor Name: | JACOB COLLIE |
| NPI Number: | 1952716276 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | D.O. |
| License Number: | |
| Business Practice Address: | Bamc, 3551 Roger Brooke Drive, Mche-qd (creds) Fort Sam Houston, Tx 78234 Apo, AA - 78234 |
| Business Phone Number: | 2109166807 |
| Business Fax Number: | |
| Mailing Address: | 3551 Roger Brooke Drive, Mche-qd (creds), Fort Sam Houston, 78234 APO |
| State: | AA |
| Postal Code: | 78234 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 06/25/2014 |
| NPI Last Update Date: | 06/25/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 390200000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Student, Health Care |
| Taxonomy Classification: | Student in an Organized Health Care Education/Training Program |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care. |