Provider Demographics
NPI:1710162672
Name:MCCORMICK, JENNIFER A (MA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 KEARNY VILLA RD
Mailing Address - Street 2:SUITE 116
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1578
Mailing Address - Country:US
Mailing Address - Phone:858-279-1223
Mailing Address - Fax:
Practice Address - Street 1:15611 POMERADO RD
Practice Address - Street 2:STE 535
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2437
Practice Address - Country:US
Practice Address - Phone:858-272-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC48233106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist