Healthcare Provider Details

I. General information

NPI: 1922994029
Provider Name (Legal Business Name): JESSICA CORNELL MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2025
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

562 SHOUP AVE W
TWIN FALLS ID
83301-5029
US

IV. Provider business mailing address

562 SHOUP AVE W
TWIN FALLS ID
83301-5029
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-0407
  • Fax:
Mailing address:
  • Phone: 208-734-0407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: