Provider Demographics
NPI:1437380763
Name:CORNELL, JENNIE L
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:L
Last Name:CORNELL
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 1:1716 9TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-4819
Mailing Address - Country:US
Mailing Address - Phone:218-790-3636
Mailing Address - Fax:
Practice Address - Street 1:914 S 12TH ST STE 101
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5941
Practice Address - Country:US
Practice Address - Phone:701-255-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
SD31181041C0700X
ND1945101YA0400X
ND38401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDP00898858OtherRAILROAD MEDICARE
SDS103725Medicare PIN