Provider Demographics
NPI:1316966674
Name:MCCOLLUM, JACKIE LYNNE (MD)
Entity type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:LYNNE
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12101 E 2ND AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80011-8328
Mailing Address - Country:US
Mailing Address - Phone:720-535-6204
Mailing Address - Fax:720-949-0540
Practice Address - Street 1:12101 E 2ND AVE STE 105
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-8328
Practice Address - Country:US
Practice Address - Phone:720-535-6204
Practice Address - Fax:720-949-0540
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28393207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01283936Medicaid
COA53104Medicare UPIN
COC529878Medicare ID - Type Unspecified