Provider Demographics
NPI:1578997136
Name:JACKSON-CANNON, NATASHA YVONNE (AG-ACNP)
Entity Type:Individual
Prefix:MRS
First Name:NATASHA
Middle Name:YVONNE
Last Name:JACKSON-CANNON
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:756 N SUNCOAST BLVD
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-9072
Mailing Address - Country:US
Mailing Address - Phone:352-346-3127
Mailing Address - Fax:352-581-6226
Practice Address - Street 1:756 N SUNCOAST BLVD
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-9072
Practice Address - Country:US
Practice Address - Phone:352-346-3127
Practice Address - Fax:352-581-6226
Is Sole Proprietor?:No
Enumeration Date:2013-08-30
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN 9355976163WS0200X
FLAPRN11006144363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WS0200XNursing Service ProvidersRegistered NurseSchool