Provider Demographics
NPI:1154138626
Name:MCCOLLOM, JESSICA REGINA RENE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:REGINA RENE
Last Name:MCCOLLOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:REGINA RENE
Other - Last Name:FURE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:712 W 32ND ST APT C
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-2081
Mailing Address - Country:US
Mailing Address - Phone:425-239-5711
Mailing Address - Fax:
Practice Address - Street 1:1498 SE TECH CENTER PL STE 300
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-5509
Practice Address - Country:US
Practice Address - Phone:360-619-2226
Practice Address - Fax:360-326-9691
Is Sole Proprietor?:No
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor