Provider Demographics
NPI:1700322377
Name:MCCORMICK, JENNIFER LYNNE (BCBA)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNNE
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1163 OLD COLONY RD UNIT 6
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-1783
Mailing Address - Country:US
Mailing Address - Phone:203-213-5953
Mailing Address - Fax:
Practice Address - Street 1:1163 OLD COLONY RD UNIT 6
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-1783
Practice Address - Country:US
Practice Address - Phone:203-213-5953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-06
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1-08-4107103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst