MEDICARE: JACQUELYNN CORNELL P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT100396	MO

General Provider Information

NPI Number	:	1982899514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELYNN CORNELL P.T.

Provider Business Mailing Address
First Line	:	439 S KIRKWOOD RD
Second Line	:	STE 100
City	:	KIRKWOOD
State	:	MO
Zip	:	63122-6169
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	439 S KIRKWOOD RD
Second Line	:	STE 100
City	:	KIRKWOOD
State	:	MO
Zip	:	63122-6169
Country	:	US
Telephone Number	:	314-822-6297
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2007
Last Update Date	:	09/06/2007

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Directions to “ JACQUELYNN CORNELL P.T.” Practice Location

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