Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080A0000X | Adolescent Medicine | 60116 | CT |
NPI | 1285933655 |
---|---|
Provider Name | Jessica Maccormac |
First Address | Hartford, CT 06106-1976 |
Second Address | Hartford, CT 06106 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/03/2011 |
Last Update Date | 11/12/2018 |