Provider Demographics
NPI:1346898145
Name:MCCORD, JACQUELINE MICHELLE (MA)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MICHELLE
Last Name:MCCORD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:MCCORD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:5974 US ROUTE 60 E
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-1035
Mailing Address - Country:US
Mailing Address - Phone:304-736-6677
Mailing Address - Fax:304-736-6677
Practice Address - Street 1:5974 US ROUTE 60 E
Practice Address - Street 2:
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504-1035
Practice Address - Country:US
Practice Address - Phone:304-736-6677
Practice Address - Fax:304-736-6677
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1234103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810002106Medicaid