Provider Demographics
NPI:1548606601
Name:CANNON, CHAD JACOB (DC)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:JACOB
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:PO BOX 700688
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78270-0688
Mailing Address - Country:US
Mailing Address - Phone:210-318-3007
Mailing Address - Fax:210-468-0682
Practice Address - Street 1:14244 POTRANCO RD STE 250
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-2145
Practice Address - Country:US
Practice Address - Phone:435-755-7654
Practice Address - Fax:435-753-7654
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7875588-1202111N00000X
TX15645111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX15645OtherCHIROPRACTIC LICENSE
UT7875588-1202OtherCHIROPRACTIC LICENSE