Healthcare Provider Details

I. General information

NPI: 1518278779
Provider Name (Legal Business Name): JILL ELIZABETH CORNELL MA, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

872 S CAMINO DEL PUEBLO VALLE DEL SOL, NEW MEXICO
BERNALILLO NM
87004-5958
US

IV. Provider business mailing address

5621 TIMBERLINE AVE NW
ALBUQUERQUE NM
87120-4659
US

V. Phone/Fax

Practice location:
  • Phone: 505-867-2383
  • Fax: 505-867-7293
Mailing address:
  • Phone: 505-463-6240
  • Fax: 505-265-4174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2086
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: