Provider Demographics
NPI:1003156191
Name:MCCORMACK, JAN G (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JAN
Middle Name:G
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BAMBERG
Mailing Address - State:SC
Mailing Address - Zip Code:29003-1726
Mailing Address - Country:US
Mailing Address - Phone:803-245-0508
Mailing Address - Fax:
Practice Address - Street 1:364 2ND ST
Practice Address - Street 2:
Practice Address - City:BAMBERG
Practice Address - State:SC
Practice Address - Zip Code:29003-1726
Practice Address - Country:US
Practice Address - Phone:803-245-0508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3589235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist