Provider Demographics
NPI:1144467622
Name:MCCORMICK, JENNIFER M (OTR)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:M
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24689 KINGS CANYON SQ
Mailing Address - Street 2:
Mailing Address - City:STONE RIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:20105-2988
Mailing Address - Country:US
Mailing Address - Phone:703-963-1514
Mailing Address - Fax:
Practice Address - Street 1:24689 KINGS CANYON SQ
Practice Address - Street 2:
Practice Address - City:STONE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:20105-2988
Practice Address - Country:US
Practice Address - Phone:703-327-9458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119001129225XP0200X, 225X00000X
225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology