Provider Demographics
NPI:1043793839
Name:MCCORMAC, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MCCORMAC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 FOLKSTONE DR
Mailing Address - Street 2:
Mailing Address - City:EAST HAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11937-1213
Mailing Address - Country:US
Mailing Address - Phone:631-946-2558
Mailing Address - Fax:
Practice Address - Street 1:240 MEETING HOUSE LN
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5009
Practice Address - Country:US
Practice Address - Phone:631-726-3300
Practice Address - Fax:631-726-3298
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-08
Last Update Date:2018-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY632605-1163WW0000X
NYF308845-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WW0000XNursing Service ProvidersRegistered NurseWound Care