Healthcare Provider Details

I. General information

NPI: 1508552522
Provider Name (Legal Business Name): JONI SUE MCCOLLUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6546 ANN RD
FRUITPORT MI
49415-9616
US

IV. Provider business mailing address

6546 ANN RD
FRUITPORT MI
49415-9616
US

V. Phone/Fax

Practice location:
  • Phone: 231-830-9339
  • Fax: 231-737-1464
Mailing address:
  • Phone: 231-830-9339
  • Fax: 231-737-1464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: