Provider Demographics
NPI:1467824953
Name:CANNON, JEREMY DOYLE (DC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DOYLE
Last Name:CANNON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2529 DAKOTA DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-7349
Mailing Address - Country:US
Mailing Address - Phone:717-385-0722
Mailing Address - Fax:
Practice Address - Street 1:704 E ARLINGTON BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5809
Practice Address - Country:US
Practice Address - Phone:252-756-6111
Practice Address - Fax:252-756-6904
Is Sole Proprietor?:No
Enumeration Date:2015-10-23
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4888111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS756Medicare UPIN