Provider Demographics
NPI:1578648689
Name:CORNELL, HEATHER RICE
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:RICE
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 1:4250 LAKESIDE DR
Mailing Address - Street 2:SUITE 116 AGING TRUE/URBAN JACKSONVILLE
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-3358
Mailing Address - Country:US
Mailing Address - Phone:904-807-1291
Mailing Address - Fax:904-807-1220
Practice Address - Street 1:4250 LAKESIDE DR
Practice Address - Street 2:SUITE 116 AGING TRUE/URBAN JACKSONVILLE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-3358
Practice Address - Country:US
Practice Address - Phone:904-807-1291
Practice Address - Fax:904-807-1220
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL766879100Medicaid