Provider Demographics
NPI:1902136294
Name:CORNISH, JEREMY DAVID (LAC)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:DAVID
Last Name:CORNISH
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5844 WALNUT AVE
Mailing Address - Street 2:APT 2C
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-6022
Mailing Address - Country:US
Mailing Address - Phone:315-368-7457
Mailing Address - Fax:
Practice Address - Street 1:5844 WALNUT AVE
Practice Address - Street 2:APT 2C
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60516-6022
Practice Address - Country:US
Practice Address - Phone:315-368-7457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-08
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198000842171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist