Provider Demographics
NPI:1093175010
Name:CANNON, JEREMY (PTA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:CANNON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 SEA ISLAND PKWY STE 103
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29907-1499
Mailing Address - Country:US
Mailing Address - Phone:843-379-3991
Mailing Address - Fax:
Practice Address - Street 1:95 SEA ISLAND PKWY STE 103
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29907-1499
Practice Address - Country:US
Practice Address - Phone:803-942-6412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-03
Last Update Date:2022-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3416225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant