Provider Demographics
NPI:1730483850
Name:MCCORMACK, JILL ANN (LMSW)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ANN
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:ANN
Other - Last Name:HALEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:19750 BURT RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-2078
Mailing Address - Country:US
Mailing Address - Phone:313-977-9550
Mailing Address - Fax:313-693-9721
Practice Address - Street 1:19750 BURT RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-2078
Practice Address - Country:US
Practice Address - Phone:313-977-9550
Practice Address - Fax:313-693-9721
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010587991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1883825Medicaid
MI1883825Medicaid