Provider Demographics
NPI:1033994595
Name:MCCOLLUM, JOHN ANTHONY (LAC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANTHONY
Last Name:MCCOLLUM
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. DRAWER 2109
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-2109
Mailing Address - Country:US
Mailing Address - Phone:479-967-2322
Mailing Address - Fax:479-967-2876
Practice Address - Street 1:2414 S 57TH ST STE 101
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3855
Practice Address - Country:US
Practice Address - Phone:479-280-9980
Practice Address - Fax:501-421-2336
Is Sole Proprietor?:No
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2308023101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor