Basic Information
Provider Information | |||||||||
NPI: | 1508043274 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCCORMACK | ||||||||
FirstName: | JEANIE | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HOSKINS | ||||||||
OtherFirstName: | JEANIE | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DO | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 23229 | ||||||||
Address2: |   | ||||||||
City: | OWENSBORO | ||||||||
State: | KY | ||||||||
PostalCode: | 423043229 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2706881330 | ||||||||
FaxNumber: | 2706881338 | ||||||||
Practice Location | |||||||||
Address1: | 1301 PLEASANT VALLEY RD | ||||||||
Address2: | SUITE 500C | ||||||||
City: | OWENSBORO | ||||||||
State: | KY | ||||||||
PostalCode: | 423039774 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2704177830 | ||||||||
FaxNumber: | 2704177839 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/24/2008 | ||||||||
LastUpdateDate: | 04/20/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 34010264 | OH | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 03682 | KY | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | 201259240 | 05 | IN |   | MEDICAID | 7100309370 | 05 | KY |   | MEDICAID |