Provider Demographics
NPI:1174706808
Name:DR JACKIE L MCCOLLUM, MD. P.C.
Entity type:Organization
Organization Name:DR JACKIE L MCCOLLUM, MD. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:MCCOLLUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-535-6204
Mailing Address - Street 1:12101 E 2ND AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80011-8327
Mailing Address - Country:US
Mailing Address - Phone:720-535-6204
Mailing Address - Fax:
Practice Address - Street 1:12101 E 2ND AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-8327
Practice Address - Country:US
Practice Address - Phone:720-535-6204
Practice Address - Fax:720-949-0540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28393305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC529878Medicare PIN