Provider Demographics
NPI:1205424074
Name:CANNON, JENNIFER (BSHS, LMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:BSHS, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 MARTELLO DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-1261
Mailing Address - Country:US
Mailing Address - Phone:305-632-1727
Mailing Address - Fax:
Practice Address - Street 1:143 MARTELLO DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-1261
Practice Address - Country:US
Practice Address - Phone:305-632-1727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-06
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA95914225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist