MEDICARE: JILL SUZANNE MCCORMICK P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	108639	MO
2	2251X0800X	Orthopedic Physical Therapist	070014339	IL
3	2251X0800X	Orthopedic Physical Therapist	PT36994	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073517520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILL SUZANNE MCCORMICK P.T.

Provider Business Mailing Address
First Line	:	121 WAUGH AVE
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95065-1133
Country	:	US
Telephone Number	:	831-566-2004
Fax Number	:	831-325-0307

Provider Business Practice Location Address
First Line	:	2650 RESEARCH PARK DR
Second Line	:
City	:	SOQUEL
State	:	CA
Zip	:	95073-2087
Country	:	US
Telephone Number	:	831-566-2004
Fax Number	:	831-325-0307

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	05/03/2016

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