Provider Demographics
NPI:1134976061
Name:CANNON PSYCHOLOGICAL LLC
Entity type:Organization
Organization Name:CANNON PSYCHOLOGICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:352-339-6751
Mailing Address - Street 1:3075 ORANGE PICKER RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-0882
Mailing Address - Country:US
Mailing Address - Phone:352-339-6751
Mailing Address - Fax:
Practice Address - Street 1:12058 SAN JOSE BLVD STE 202
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8669
Practice Address - Country:US
Practice Address - Phone:043-738-2999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-30
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health