Provider Demographics
NPI:1417681826
Name:MCCORMICK, JACQUELINE J
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:J
Last Name:MCCORMICK
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 1:25110 WATERLEAF LN
Mailing Address - Street 2:
Mailing Address - City:FLAT ROCK
Mailing Address - State:MI
Mailing Address - Zip Code:48134-8814
Mailing Address - Country:US
Mailing Address - Phone:248-835-3028
Mailing Address - Fax:
Practice Address - Street 1:189 W CLARKSTON RD
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-2892
Practice Address - Country:US
Practice Address - Phone:844-642-9273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022373101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health