Provider Demographics
NPI:1821791336
Name:CANNON, KING EDWARD JR
Entity Type:Individual
Prefix:MR
First Name:KING
Middle Name:EDWARD
Last Name:CANNON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7384 JOHN LEBLANC BLVD
Mailing Address - Street 2:
Mailing Address - City:SORRENTO
Mailing Address - State:LA
Mailing Address - Zip Code:70778-3231
Mailing Address - Country:US
Mailing Address - Phone:225-310-2600
Mailing Address - Fax:
Practice Address - Street 1:7384 JOHN LEBLANC BLVD
Practice Address - Street 2:
Practice Address - City:SORRENTO
Practice Address - State:LA
Practice Address - Zip Code:70778-3231
Practice Address - Country:US
Practice Address - Phone:225-310-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
LA175T00000X101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)