Provider Demographics
NPI:1710652482
Name:CANNON, JORDAN ASHLEY (BS)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ASHLEY
Last Name:CANNON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 SAINT JAMES CT
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-4288
Mailing Address - Country:US
Mailing Address - Phone:864-940-1809
Mailing Address - Fax:
Practice Address - Street 1:1501 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-3113
Practice Address - Country:US
Practice Address - Phone:434-544-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer