Provider Demographics
NPI:1134611254
Name:CANNON, JA'REALLE MONET
Entity type:Individual
Prefix:
First Name:JA'REALLE
Middle Name:MONET
Last Name:CANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3821 HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:RACELAND
Mailing Address - State:LA
Mailing Address - Zip Code:70394-3146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1516 1/2 MENVILLE ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-6532
Practice Address - Country:US
Practice Address - Phone:504-453-8147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator