Provider Demographics
NPI:1174929293
Name:CORNMAN, JESSICA BRAUN (DPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:BRAUN
Last Name:CORNMAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10516 PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-8405
Mailing Address - Country:US
Mailing Address - Phone:704-541-9080
Mailing Address - Fax:
Practice Address - Street 1:10516 PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8405
Practice Address - Country:US
Practice Address - Phone:704-541-9080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-17
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT28486225100000X
NC15205225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist