Provider Demographics
NPI:1770628067
Name:CANNON, JACKIE B (DPT)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:B
Last Name:CANNON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35111 SEAGRASS PLANTATION LN
Mailing Address - Street 2:
Mailing Address - City:DAGSBORO
Mailing Address - State:DE
Mailing Address - Zip Code:19939-3391
Mailing Address - Country:US
Mailing Address - Phone:866-484-8193
Mailing Address - Fax:888-516-4393
Practice Address - Street 1:35111 SEAGRASS PLANTATION LN
Practice Address - Street 2:
Practice Address - City:DAGSBORO
Practice Address - State:DE
Practice Address - Zip Code:19939
Practice Address - Country:US
Practice Address - Phone:866-484-8193
Practice Address - Fax:888-516-4393
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC69942251X0800X
PAPT003408L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA396648Medicare Oscar/Certification