Provider Demographics
NPI:1801307848
Name:MCCORMICK, JANETTA FAE (LCSW)
Entity type:Individual
Prefix:
First Name:JANETTA
Middle Name:FAE
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:JANETTA
Other - Middle Name:FAE
Other - Last Name:MCCORMICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 392552
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15251-9500
Mailing Address - Country:US
Mailing Address - Phone:260-483-9081
Mailing Address - Fax:260-483-9196
Practice Address - Street 1:3512 STELLHORN RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4631
Practice Address - Country:US
Practice Address - Phone:260-483-9081
Practice Address - Fax:260-483-9196
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-17
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34006849A101YP2500X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional