=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689875122
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELINE JONAS MCCOLLUM LMHC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 217 N 14TH ST
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34748-4821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-365-1098
-----------------------------------------------------
Fax | 352-365-2334
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1318 SPRINGLAKE RD
-----------------------------------------------------
City | FRUITLAND PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-728-8539
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH 5473
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------