Provider Demographics
NPI:1447693379
Name:MACCOLLUM, JENNIFER (MS ED)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MACCOLLUM
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 AUDUBON ST
Mailing Address - Street 2:APARTMENT 4
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14610-1552
Mailing Address - Country:US
Mailing Address - Phone:585-469-6160
Mailing Address - Fax:
Practice Address - Street 1:700 COTTAGE BROOK LN
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-8654
Practice Address - Country:US
Practice Address - Phone:585-797-9366
Practice Address - Fax:585-486-1230
Is Sole Proprietor?:No
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1387895171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator