Provider Demographics
NPI:1518269521
Name:MCCORMACK, JILL MARIE (MOTR/L)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9852 NW 6TH PL
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-4939
Mailing Address - Country:US
Mailing Address - Phone:413-519-1432
Mailing Address - Fax:
Practice Address - Street 1:5301 N FEDERAL HWY
Practice Address - Street 2:SUITE 135
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-4917
Practice Address - Country:US
Practice Address - Phone:561-674-0016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-23
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11996225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist