Provider Demographics
NPI:1578842258
Name:CANNON, JEREMY JON
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:JON
Last Name:CANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5110 S FLORIDA AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2517
Mailing Address - Country:US
Mailing Address - Phone:863-450-9864
Mailing Address - Fax:
Practice Address - Street 1:5110 S FLORIDA AVE STE 105
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2517
Practice Address - Country:US
Practice Address - Phone:863-450-9864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor