Provider Demographics
NPI:1689832883
Name:CORNELIUS, JAMIE (MSPT, ATC/L)
Entity Type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:MSPT, ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 242A
Mailing Address - Street 2:
Mailing Address - City:JASONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47438-9755
Mailing Address - Country:US
Mailing Address - Phone:812-665-2185
Mailing Address - Fax:
Practice Address - Street 1:RR 1 BOX 242A
Practice Address - Street 2:
Practice Address - City:JASONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47438-9755
Practice Address - Country:US
Practice Address - Phone:812-665-2185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-26
Last Update Date:2008-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN050066834A225100000X
IN36000607A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer