Provider Demographics
NPI:1003419672
Name:CORRELL, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CORRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1912 STARLING ST APT 209
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-4389
Mailing Address - Country:US
Mailing Address - Phone:757-269-8162
Mailing Address - Fax:
Practice Address - Street 1:108 ROCKY TOP RD
Practice Address - Street 2:
Practice Address - City:MOYOCK
Practice Address - State:NC
Practice Address - Zip Code:27958-9284
Practice Address - Country:US
Practice Address - Phone:757-769-9595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician