Provider Demographics
NPI:1407833684
Name:MCCOLLOW, JERRY J (PT)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:J
Last Name:MCCOLLOW
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9190 N COACHLINE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85743
Mailing Address - Country:US
Mailing Address - Phone:520-308-4879
Mailing Address - Fax:520-308-4874
Practice Address - Street 1:9190 N COACHLINE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85743
Practice Address - Country:US
Practice Address - Phone:520-308-4879
Practice Address - Fax:520-308-4874
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ1391225100000X
AZLPT-001391225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
71847Medicare ID - Type Unspecified