Provider Demographics
NPI:1629743414
Name:CORNEJO, JOHN ANDREW
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ANDREW
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 1:1475 DARLENE DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-3908
Mailing Address - Country:US
Mailing Address - Phone:925-852-8624
Mailing Address - Fax:
Practice Address - Street 1:3800 COOLIDGE AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-3311
Practice Address - Country:US
Practice Address - Phone:510-482-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-12
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician