Provider Demographics
NPI:1265241293
Name:KINCANNON, JACQUELINE ANN-MARIE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN-MARIE
Last Name:KINCANNON
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 1:12470 STARCREST DR APT 413
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-2979
Mailing Address - Country:US
Mailing Address - Phone:210-929-0895
Mailing Address - Fax:
Practice Address - Street 1:12470 STARCREST DR APT 413
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-2979
Practice Address - Country:US
Practice Address - Phone:210-929-0895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-03
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health