Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 108639 | MO |
N | 2251X0800X | Physical Therapist - Orthopedic | 070014339 | IL |
Y | 2251X0800X | Physical Therapist - Orthopedic | PT36994 | CA |
NPI | 1073517520 |
---|---|
Provider Name | Jill Suzanne Mccormick |
First Address | Santa Cruz, CA 95065-1133 |
Second Address | Soquel, CA 95073-2087 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2005 |
Last Update Date | 03/05/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
484700802 | (05) | MO |