Provider Demographics
NPI:1043793839
Name:MCCORMAC, JENNIFER (AGNP, CWON)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MCCORMAC
Suffix:
Gender:F
Credentials:AGNP, CWON
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2921 BELLPORT AVE
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-4511
Mailing Address - Country:US
Mailing Address - Phone:631-946-2558
Mailing Address - Fax:
Practice Address - Street 1:1315 YORK AVE FL 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-5304
Practice Address - Country:US
Practice Address - Phone:646-962-2270
Practice Address - Fax:212-746-6370
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-08
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY632605-1163WW0000X
NYF308845-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WW0000XNursing Service ProvidersRegistered NurseWound Care