Provider Demographics
NPI:1225003379
Name:CANNON, JILL (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 ALLISON RD
Mailing Address - Street 2:
Mailing Address - City:KATONAH
Mailing Address - State:NY
Mailing Address - Zip Code:10536-3430
Mailing Address - Country:US
Mailing Address - Phone:914-401-9010
Mailing Address - Fax:914-401-9009
Practice Address - Street 1:130 ALLISON RD
Practice Address - Street 2:
Practice Address - City:KATONAH
Practice Address - State:NY
Practice Address - Zip Code:10536-3430
Practice Address - Country:US
Practice Address - Phone:914-401-9010
Practice Address - Fax:914-401-9009
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0190571103TA0400X, 103TC0700X, 103TF0000X, 103TF0200X, 1041C0700X
NYR#019571103T00000X
NY019571103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
140019057NY01OtherANTHEM
135497OtherVALUE OPTIONS
135497OtherVALUE OPTIONS