Provider Demographics
NPI:1558536490
Name:CANNON, JACQUELYN DANETTE (ARNP)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:DANETTE
Last Name:CANNON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:11513 N MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4002
Practice Address - Country:US
Practice Address - Phone:855-674-7400
Practice Address - Fax:904-730-1037
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9169833363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP9169833OtherFLORIDA BOARD OF NUSING LICENSE #
GA580304754AMedicaid
FL0031120-00Medicaid
FL0031120-00Medicaid
FLARNP9169833OtherFLORIDA BOARD OF NUSING LICENSE #
FLAW451XMedicare PIN
FLAW451ZMedicare PIN
GA003104660AMedicaid