Provider Demographics
NPI:1255978565
Name:MCCORMACK, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:MCCORMACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 N OAKLAND AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1647
Mailing Address - Country:US
Mailing Address - Phone:209-614-3560
Mailing Address - Fax:
Practice Address - Street 1:13651 WILLARD STREET
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402
Practice Address - Country:US
Practice Address - Phone:833-574-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-05
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist