Healthcare Provider Details

I. General information

NPI: 1124121371
Provider Name (Legal Business Name): JACINDA ANNE CORNICK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 N SHERIDAN RD
PEORIA IL
61614-2932
US

IV. Provider business mailing address

6501 N SHERIDAN RD
PEORIA IL
61614-2932
US

V. Phone/Fax

Practice location:
  • Phone: 309-692-8110
  • Fax: 309-692-8673
Mailing address:
  • Phone: 309-692-8110
  • Fax: 309-692-8673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085001587
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085-001587
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: