Provider Demographics
NPI:1346494978
Name:CANNON, KERRY A (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:KERRY
Middle Name:A
Last Name:CANNON
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:MS
Other - First Name:KERRY
Other - Middle Name:A
Other - Last Name:PAYTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BLS, LPHA, MSW
Mailing Address - Street 1:1577 PENNSYLVANIA CT
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-9203
Mailing Address - Country:US
Mailing Address - Phone:209-592-0009
Mailing Address - Fax:
Practice Address - Street 1:1577 PENNSYLVANIA CT
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-9203
Practice Address - Country:US
Practice Address - Phone:323-798-7413
Practice Address - Fax:833-419-0181
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-10
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA803951041C0700X, 1041C0700X
CA33557104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1346494978Medicaid