Provider Demographics
NPI:1285041269
Name:MCCOLLISTER, JESSICA (LPN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MCCOLLISTER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 WILLOWICK DR
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-8944
Mailing Address - Country:US
Mailing Address - Phone:585-944-9570
Mailing Address - Fax:
Practice Address - Street 1:3 WILLOWICK DR
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-8944
Practice Address - Country:US
Practice Address - Phone:585-944-9570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-22
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY318963251E00000X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY318963Medicaid