Provider Demographics
NPI:1003578402
Name:CORNELIUS, JESSICA LEE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEE
Other - Last Name:PUCKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2201 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2411
Mailing Address - Country:US
Mailing Address - Phone:701-515-8117
Mailing Address - Fax:
Practice Address - Street 1:629 21ST ST S APT 4
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2487
Practice Address - Country:US
Practice Address - Phone:701-353-9257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty