Healthcare Provider Details

I. General information

NPI: 1447114624
Provider Name (Legal Business Name): JILLISA MCCOLLUM-JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 ROBINSON ST
BINGHAMTON NY
13904-1735
US

IV. Provider business mailing address

1010 BUTTONWOOD DR
HARRISBURG PA
17109-5307
US

V. Phone/Fax

Practice location:
  • Phone: 717-379-8187
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number936820
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: