Provider Demographics
NPI:1790396703
Name:CANNON, JERMAINE (LMT)
Entity Type:Individual
Prefix:MR
First Name:JERMAINE
Middle Name:
Last Name:CANNON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 NICOLE CT
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:DE
Mailing Address - Zip Code:19720-3762
Mailing Address - Country:US
Mailing Address - Phone:302-377-5838
Mailing Address - Fax:
Practice Address - Street 1:1 MURPHY RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3044
Practice Address - Country:US
Practice Address - Phone:302-543-4004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEMT-0003237174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist