=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528875861
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA DEANN CORNELISON FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2024
-----------------------------------------------------
Last Update Date | 07/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27 CARTER 370
-----------------------------------------------------
City | ELLSINORE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63937-8191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-944-7078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27 CARTER 370
-----------------------------------------------------
City | ELLSINORE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63937-8191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-944-7078
-----------------------------------------------------
Fax | 850-732-8016
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0000X
-----------------------------------------------------
Taxonomy Name | Adolescent Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 2019019286
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number | 2019019286
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 2019019286
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 2019019286
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 2019019286
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------