Provider Demographics
NPI:1073517520
Name:MCCORMICK, JILL SUZANNE (PT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:SUZANNE
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 WAUGH AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-1133
Mailing Address - Country:US
Mailing Address - Phone:831-566-2004
Mailing Address - Fax:831-325-0307
Practice Address - Street 1:2650 RESEARCH PARK DR
Practice Address - Street 2:
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073-2087
Practice Address - Country:US
Practice Address - Phone:831-566-2004
Practice Address - Fax:831-325-0307
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108639225100000X
IL0700143392251X0800X
CAPT369942251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO484700802Medicaid
MO168500001Medicare PIN