Most Relevant Information
Provider Data
| NPI Number: | 1003578402 |
| Provider Name: | JESSICA LEE CORNELIUS |
| Entity Type: | Individual |
| Taxonomy Code: | 3747P1801X |
| Specialty: | Technician |
| License Number: |
Most Important Dates
| Enumeration Date: | 10/13/2021 |
| Last Updated: | 10/13/2021 |
Provider Practice Location
629 21ST ST S APT 4
FARGO
ND
581032487
Practice Location Phone/Fax
| Phone: | 7013539257 |
| Fax: |
Provider Mailing Location
2201 6TH AVE S
FARGO
ND
581032411
Provider Mailing Phone/Fax
| Phone: | 7015158117 |
| Fax: |