Provider Demographics
NPI:1154155794
Name:VEGA CORNELIO, JEANELLE
Entity type:Individual
Prefix:
First Name:JEANELLE
Middle Name:
Last Name:VEGA CORNELIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 E 54TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98404-2601
Mailing Address - Country:US
Mailing Address - Phone:253-304-2384
Mailing Address - Fax:
Practice Address - Street 1:2201 S 19TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2962
Practice Address - Country:US
Practice Address - Phone:253-697-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor