Provider Demographics
NPI:1417107806
Name:DURST CANNON, JESSICA DAUGHN (DO)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:DAUGHN
Last Name:DURST CANNON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:DURST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1920 MALVERN AVE
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-7752
Mailing Address - Country:US
Mailing Address - Phone:801-321-1314
Mailing Address - Fax:501-321-1810
Practice Address - Street 1:1920 MALVERN AVE
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-7752
Practice Address - Country:US
Practice Address - Phone:801-321-1314
Practice Address - Fax:501-321-1810
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102203494208000000X
ARE-9592208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR212848003Medicaid