Active NPI
Colletta Latoya Jerrick, NURSE PRACTITIONER
- Psychiatric/Mental Health Nurse Practitioner
- Bay Shore, NY
National Provider Identifier
1922720887
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychiatric/Mental Health Nurse Practitioner
- License
- F403813-01
- Practice address
- 1548 E Forks Rd
Bay Shore, NY 11706-3144 - Phone
- (631) 308-7658
- NPI assigned
- Sep 16, 2022
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychiatric/Mental Health Nurse Practitioner | 363LP0808X | F403813-01 | NY | Primary |
Addresses
Primary practice location
1548 E Forks Rd
Bay Shore, NY 11706-3144
Mailing address
1548 E Forks Rd
Bay Shore, NY 11706-3144
Phone (631) 308-7658
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| F403813-01 | Other | NY | NEW YORK STATE OFFICE OF THE PROFESSIONS |
Electronic endpoints 1
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| CONNECT URL | Strongwoman1680@yahoo.com | Direct |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| F403813-01 | NY | MD | Psychiatric/Mental Health Nurse Practitioner |
Interoperability endpoints
- lifestancehealth.collettajerrick@142175.advancedmd-direct.com
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1663286400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1663286400000",
"number": "1922720887",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1548 E FORKS RD",
"city": "BAY SHORE",
"state": "NY",
"postal_code": "117063144",
"telephone_number": "631-308-7658"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1548 E FORKS RD",
"city": "BAY SHORE",
"state": "NY",
"postal_code": "117063144",
"telephone_number": "631-308-7658"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JERRICK",
"first_name": "COLLETTA",
"middle_name": "LATOYA",
"credential": "NURSE PRACTITIONER",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2022-09-16",
"last_updated": "2022-09-16",
"certification_date": "2022-09-15",
"status": "A"
},
"taxonomies": [
{
"code": "363LP0808X",
"taxonomy_group": "",
"desc": "Nurse Practitioner, Psychiatric/Mental Health",
"state": "NY",
"license": "F403813-01",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "NEW YORK STATE OFFICE OF THE PROFESSIONS",
"identifier": "F403813-01",
"state": "NY"
}
],
"endpoints": [
{
"endpointType": "CONNECT",
"endpointTypeDescription": "CONNECT URL",
"endpoint": "Strongwoman1680@yahoo.com",
"affiliation": "N",
"endpointDescription": "Strongwoman1680@yahoo.com",
"use": "DIRECT",
"useDescription": "Direct",
"contentType": "CSV",
"contentTypeDescription": "CSV",
"address_1": "1548 E Forks Rd",
"city": "Bay Shore",
"state": "NY",
"country_code": "US",
"postal_code": "117063144",
"country_name": "United States",
"address_type": "DOM"
}
],
"other_names": []
}Other providers in Bay Shore, NY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 16, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.