Provider Demographics
NPI:1922051424
Name:CANNON, JENIFER M (MD)
Entity Type:Individual
Prefix:DR
First Name:JENIFER
Middle Name:M
Last Name:CANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:JENIFER
Other - Middle Name:M
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:12639 OLD TESSON RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2786
Mailing Address - Country:US
Mailing Address - Phone:314-849-0311
Mailing Address - Fax:314-849-4423
Practice Address - Street 1:9701 LANDMARK PARKWAY DR
Practice Address - Street 2:SUITE 207
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1665
Practice Address - Country:US
Practice Address - Phone:314-842-4802
Practice Address - Fax:314-849-8721
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8J94207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO4225543OtherAETNA
MO0700221OtherUNITED HEALTHCARE
MO112746OtherBLUE CROSS BLUE SHIELD
MO174439OtherHEALTHLINK
MO112746OtherBLUE CROSS BLUE SHIELD