Provider Demographics
NPI:1457838815
Name:JONES-CANNON, BROOKE NICOLE (OD)
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:NICOLE
Last Name:JONES-CANNON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 ROGOSIN DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2906
Mailing Address - Country:US
Mailing Address - Phone:423-543-6868
Mailing Address - Fax:423-543-4226
Practice Address - Street 1:210 ROGOSIN DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2906
Practice Address - Country:US
Practice Address - Phone:423-543-6868
Practice Address - Fax:423-543-4226
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT3491152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1891831160Medicaid