Provider Demographics
NPI:1598509655
Name:CORNEJO, JOSE
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:CORNEJO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3312 CLINTON PKWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66047-3624
Mailing Address - Country:US
Mailing Address - Phone:785-841-4138
Mailing Address - Fax:
Practice Address - Street 1:6950 SQUIBB RD STE 430
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:KS
Practice Address - Zip Code:66202-3258
Practice Address - Country:US
Practice Address - Phone:913-222-8225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4175101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)