Provider Demographics
NPI:1790246650
Name:CORNELL, JONATHAN LEE
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:LEE
Last Name:CORNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 CHAPLIN RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:40008-7125
Mailing Address - Country:US
Mailing Address - Phone:646-418-4043
Mailing Address - Fax:
Practice Address - Street 1:262 CHAPLIN RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:KY
Practice Address - Zip Code:40008-7125
Practice Address - Country:US
Practice Address - Phone:646-418-4043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY246179101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional