Provider Demographics
NPI:1437570090
Name:GANNON, JODI
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:GANNON
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 1:41278 LAMBORN MESA RD
Mailing Address - Street 2:
Mailing Address - City:PAONIA
Mailing Address - State:CO
Mailing Address - Zip Code:81428-6432
Mailing Address - Country:US
Mailing Address - Phone:970-527-7666
Mailing Address - Fax:
Practice Address - Street 1:41278 LAMBORN MESA RD
Practice Address - Street 2:
Practice Address - City:PAONIA
Practice Address - State:CO
Practice Address - Zip Code:81428-6432
Practice Address - Country:US
Practice Address - Phone:970-527-7666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-30
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0012638174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist