Provider Demographics
NPI:1245813930
Name:CORNEJO, JESSICA RAE (CRNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:RAE
Last Name:CORNEJO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 THAMES ST UNIT 202
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-3466
Mailing Address - Country:US
Mailing Address - Phone:240-252-9793
Mailing Address - Fax:
Practice Address - Street 1:8600 LASALLE RD
Practice Address - Street 2:#250B
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286
Practice Address - Country:US
Practice Address - Phone:443-798-9029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR207271363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner