Healthcare Provider Details

I. General information

NPI: 1235235607
Provider Name (Legal Business Name): JESSICA M CORNELIUS PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

478 WHIRLAWAY DR STE 100
DANVILLE KY
40422-9037
US

IV. Provider business mailing address

PO BOX 1080
BURKESVILLE KY
42717-1080
US

V. Phone/Fax

Practice location:
  • Phone: 859-236-6613
  • Fax: 859-236-2284
Mailing address:
  • Phone: 270-864-1472
  • Fax: 270-864-1693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA515
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: