Provider Demographics
NPI:1881204014
Name:MCCALLUM, JESSICA (MA, LAC, NCC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MCCALLUM
Suffix:
Gender:F
Credentials:MA, LAC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 N CENTRAL AVE STE 550
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2635
Mailing Address - Country:US
Mailing Address - Phone:602-230-7373
Mailing Address - Fax:
Practice Address - Street 1:235 W WESTERN AVE
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-1848
Practice Address - Country:US
Practice Address - Phone:602-230-7373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-18234101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health