Provider Demographics
NPI:1689875122
Name:MCCOLLUM, JACQUELINE JONAS (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:JONAS
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 SPRINGLAKE RD
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:34731
Mailing Address - Country:US
Mailing Address - Phone:352-728-8539
Mailing Address - Fax:
Practice Address - Street 1:217 N 14TH ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-4821
Practice Address - Country:US
Practice Address - Phone:352-365-1098
Practice Address - Fax:352-365-2334
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 5473101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ9825OtherBCBS NUMBER