Healthcare Provider Details

I. General information

NPI: 1972150829
Provider Name (Legal Business Name): JAMES MCCORD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2019
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 E STATE BLVD
FORT WAYNE IN
46805-4728
US

IV. Provider business mailing address

2500 E STATE BLVD
FORT WAYNE IN
46805-4728
US

V. Phone/Fax

Practice location:
  • Phone: 260-426-5431
  • Fax:
Mailing address:
  • Phone: 260-426-5431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number150111260
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: