Provider Demographics
NPI:1073809786
Name:CORNETT, JEANNE SOVEK (RN)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:SOVEK
Last Name:CORNETT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:PENINSULA
Other - Middle Name:PEDIATRIC
Other - Last Name:SERVICES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3021 CAMROSE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-8712
Mailing Address - Country:US
Mailing Address - Phone:757-525-2595
Mailing Address - Fax:757-273-1133
Practice Address - Street 1:3021 CAMROSE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-8712
Practice Address - Country:US
Practice Address - Phone:757-525-2595
Practice Address - Fax:757-273-1133
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-21
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001193123171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0163860650Medicaid
VA0163860817Medicaid
VA0163868802Medicaid