Provider Demographics
NPI:1790183713
Name:CORCORAN, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CORCORAN
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 1:6515 GEORGE WASHINGTON MEM HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23692-2182
Mailing Address - Country:US
Mailing Address - Phone:757-877-9140
Mailing Address - Fax:757-877-3925
Practice Address - Street 1:6515 GEORGE WASHINGTON MEM HWY STE 100
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23692-2182
Practice Address - Country:US
Practice Address - Phone:757-877-9140
Practice Address - Fax:757-877-3925
Is Sole Proprietor?:No
Enumeration Date:2014-12-08
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX58149104100000X
NCC0095441041C0700X
VA09040093761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker