Provider Demographics
NPI:1962016071
Name:O'CONNOR, JACK DORSEY (MS, PMHNP)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:DORSEY
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:MS, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 N CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14604-1400
Mailing Address - Country:US
Mailing Address - Phone:585-602-3749
Mailing Address - Fax:585-546-2799
Practice Address - Street 1:150 N CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14604-1400
Practice Address - Country:US
Practice Address - Phone:585-275-3511
Practice Address - Fax:585-546-2799
Is Sole Proprietor?:No
Enumeration Date:2020-09-04
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF402984363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health