Provider Demographics
NPI:1750635843
Name:CORNEJO, JORGE EDUARDO
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:EDUARDO
Last Name:CORNEJO
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 1:4369 ELENA PL QUARTZ HILL
Mailing Address - Street 2:
Mailing Address - City:QUARTZ HILL
Mailing Address - State:CA
Mailing Address - Zip Code:93536
Mailing Address - Country:US
Mailing Address - Phone:661-917-9674
Mailing Address - Fax:661-943-7088
Practice Address - Street 1:4369 ELENA PLACE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536
Practice Address - Country:US
Practice Address - Phone:661-917-9674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26048225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist