Provider Demographics
NPI:1659127843
Name:CORNEJO, LAISHA JAZMIN
Entity type:Individual
Prefix:
First Name:LAISHA
Middle Name:JAZMIN
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 1:10419 MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60164-1550
Mailing Address - Country:US
Mailing Address - Phone:773-931-0758
Mailing Address - Fax:
Practice Address - Street 1:1721 MOON LAKE BLVD STE 140
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-1070
Practice Address - Country:US
Practice Address - Phone:312-965-2997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician