Provider Demographics
NPI:1003604083
Name:MCCOLLUM, JESSICA (LMT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MCCOLLUM
Suffix:
Gender:
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5954 CHIPPEWA TRL
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:MI
Mailing Address - Zip Code:48756-8650
Mailing Address - Country:US
Mailing Address - Phone:989-510-8585
Mailing Address - Fax:
Practice Address - Street 1:3292 N M 33
Practice Address - Street 2:
Practice Address - City:ROSE CITY
Practice Address - State:MI
Practice Address - Zip Code:48654-9416
Practice Address - Country:US
Practice Address - Phone:989-685-2631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501016734225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist