Provider Demographics
NPI:1013515238
Name:CANNON, JENNIFER (MHPS-PSS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:MHPS-PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2079
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77383-2079
Mailing Address - Country:US
Mailing Address - Phone:832-554-6541
Mailing Address - Fax:
Practice Address - Street 1:1411 WUNSCHE LOOP
Practice Address - Street 2:#2079
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77373-2079
Practice Address - Country:US
Practice Address - Phone:832-554-6541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X, 172A00000X, 174H00000X, 261QM0801X
TX50025-0820175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171400000XOther Service ProvidersHealth & Wellness Coach
No172A00000XOther Service ProvidersDriver
No174H00000XOther Service ProvidersHealth Educator
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD18305791Medicaid
TX50025-0821OtherTEXAS CERTIFICATION BOARD