Provider Demographics
NPI:1558906206
Name:CORNELIUS, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CORNELIUS
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:PO BOX 1528
Mailing Address - Street 2:
Mailing Address - City:DANIA
Mailing Address - State:FL
Mailing Address - Zip Code:33004-1528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26 SW 7TH AVE
Practice Address - Street 2:
Practice Address - City:DANIA
Practice Address - State:FL
Practice Address - Zip Code:33004-3215
Practice Address - Country:US
Practice Address - Phone:954-303-6496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-15
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other