Provider Demographics
NPI:1235765207
Name:MCCOLLUM, JENNIFER DAWN (ATC-L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:ATC-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 FORRESTDALE DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27712-2981
Mailing Address - Country:US
Mailing Address - Phone:919-812-0151
Mailing Address - Fax:
Practice Address - Street 1:110 WHITFORD DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27708-9982
Practice Address - Country:US
Practice Address - Phone:919-668-5744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-21
Last Update Date:2020-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC01902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer