Basic Information
| Provider Information | |||||||||
| NPI: | 1215964499 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORRY | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8086 SOMERSET KNLS | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551252362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512629768 | ||||||||
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| Practice Location | |||||||||
| Address1: | 225 SMITH AVE N | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551022533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512418613 | ||||||||
| FaxNumber: | 6512417272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 11/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 47463 | WI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.