Provider Demographics
NPI:1629231261
Name:JEAN S. CANNON, PSY.D., INC
Entity Type:Organization
Organization Name:JEAN S. CANNON, PSY.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:717-393-9388
Mailing Address - Street 1:1681 CROWN AVE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-6303
Mailing Address - Country:US
Mailing Address - Phone:717-393-9388
Mailing Address - Fax:
Practice Address - Street 1:1681 CROWN AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-6303
Practice Address - Country:US
Practice Address - Phone:717-393-9388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-03
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1558528OtherGATEWAY MEDICARE ASSURED
PA4101535870OtherCBHNP
PA101535870-0001Medicaid
PACA1850139OtherHIGHMARK BLUE SHIELD
PA4101535870OtherCBHNP
PAQ68286Medicare UPIN