Healthcare Provider Details

I. General information

NPI: 1528875861
Provider Name (Legal Business Name): JESSICA DEANN CORNELISON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA DEANN ELKINS

II. Dates (important events)

Enumeration Date: 12/11/2024
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 CARTER 370
ELLSINORE MO
63937-8191
US

IV. Provider business mailing address

27 CARTER 370
ELLSINORE MO
63937-8191
US

V. Phone/Fax

Practice location:
  • Phone: 573-944-7078
  • Fax:
Mailing address:
  • Phone: 573-944-7078
  • Fax: 850-732-8016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number2019019286
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number2019019286
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2019019286
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2019019286
License Number StateMO
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2019019286
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: