Provider Demographics
NPI:1669423323
Name:MCCORMICK, JENNIFER JANE (PA)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:JANE
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 CORMIER RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-4824
Mailing Address - Country:US
Mailing Address - Phone:920-494-9685
Mailing Address - Fax:
Practice Address - Street 1:300 N COMMERCIAL ST
Practice Address - Street 2:SUITE 200
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2619
Practice Address - Country:US
Practice Address - Phone:920-886-0818
Practice Address - Fax:920-886-0773
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1908363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42875200Medicaid
WI42875200Medicaid
0070S73601Medicare ID - Type Unspecified