Healthcare Provider Details

I. General information

NPI: 1700601291
Provider Name (Legal Business Name): JESSICA ELIZABETH MCCORMICK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA ELIZABETH THOMAS

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22461 ANTONIO PKWY STE 135
RANCHO SANTA MARGARITA CA
92688-2806
US

IV. Provider business mailing address

PO BOX 6123
MC LEAN VA
22106-6123
US

V. Phone/Fax

Practice location:
  • Phone: 949-207-3266
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15174
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA68833
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: