Healthcare Provider Details

I. General information

NPI: 1891679270
Provider Name (Legal Business Name): JONATHAN CORNELL LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 YORK RD STE 14
TIMONIUM MD
21093-6211
US

IV. Provider business mailing address

1205 YORK RD STE 14
TIMONIUM MD
21093-6211
US

V. Phone/Fax

Practice location:
  • Phone: 410-757-2077
  • Fax:
Mailing address:
  • Phone: 410-757-2077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC16289
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: