Provider Demographics
NPI:1861831711
Name:CANNON, JENNIFER ANNE (DO)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANNE
Last Name:CANNON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:ANNE
Other - Last Name:DYCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3554 ROUND BARN BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-0929
Mailing Address - Country:US
Mailing Address - Phone:707-571-3778
Mailing Address - Fax:
Practice Address - Street 1:3554 ROUND BARN BLVD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-0929
Practice Address - Country:US
Practice Address - Phone:707-571-3778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-24
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA162362084P0800X
MI53150600842084P0800X
PAOS0186952084P0015X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty