Provider Demographics
NPI:1770897274
Name:CORNWELL, JEREMY (DPT)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:CORNWELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 940
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:WA
Mailing Address - Zip Code:98236-0940
Mailing Address - Country:US
Mailing Address - Phone:360-341-1731
Mailing Address - Fax:360-341-1053
Practice Address - Street 1:8786 STATE ROUTE 525
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:WA
Practice Address - Zip Code:98236
Practice Address - Country:US
Practice Address - Phone:360-341-1731
Practice Address - Fax:360-341-1053
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60041805225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0598COOtherREGENCE
WA0695COOtherREGENCE
WAP00893790OtherRAILROAD MEDICARE
WA0266242OtherDEPT OF L&I
WA0266279OtherDEPT OF L&I
WA0597COOtherREGENCE
WA0603COOtherREGENCE
WA0605COOtherREGENCE
WA0266257OtherDEPT OF L&I
WA0599COOtherREGENCE
WA0645COOtherREGENCE
WA0603COOtherREGENCE
WAG8894111Medicare PIN