Provider Demographics
NPI:1770971764
Name:CORNWELL, JESSE
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:CORNWELL
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 1:3225 N FRANKLIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073-4003
Mailing Address - Country:US
Mailing Address - Phone:540-251-5002
Mailing Address - Fax:
Practice Address - Street 1:3225 N FRANKLIN ST STE 2
Practice Address - Street 2:
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073
Practice Address - Country:US
Practice Address - Phone:540-251-5002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-30
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
237700000X
FLAS5012237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist