Provider Demographics
NPI:1285933655
Name:MACCORMAC, JESSICA (DO)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MACCORMAC
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 COLUMBUS BLVD FL 4
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-1976
Mailing Address - Country:US
Mailing Address - Phone:860-837-7681
Mailing Address - Fax:860-837-5361
Practice Address - Street 1:282 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106
Practice Address - Country:US
Practice Address - Phone:860-837-7681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-24
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT601162080A0000X
NY276207208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine