Provider Demographics
NPI:1356822191
Name:CANNON, JASMINE M
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:M
Last Name:CANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7126 BIDFORD CT
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29707-5822
Mailing Address - Country:US
Mailing Address - Phone:314-814-2017
Mailing Address - Fax:
Practice Address - Street 1:8420 UNIVERSITY EXEC PARK DR STE 810
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-1346
Practice Address - Country:US
Practice Address - Phone:704-894-9678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician