Basic Information
Provider Information
NPI: 1003002734
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MCCOLLUM
FirstName: JONATHAN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: LCSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1451 DOWELL SPRINGS BLVD
Address2:  
City: KNOXVILLE
State: TN
PostalCode: 379092441
CountryCode: US
TelephoneNumber: 8653747123
FaxNumber: 8653747129
Practice Location
Address1: 210 SIMMONS ST
Address2:  
City: MARYVILLE
State: TN
PostalCode: 378014750
CountryCode: US
TelephoneNumber: 8659709800
FaxNumber: 8653747129
Other Information
ProviderEnumerationDate: 09/17/2007
LastUpdateDate: 06/11/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
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AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101Y00000X  N Behavioral Health & Social Service ProvidersCounselor 
1041C0700X6020TNY Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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