Provider Demographics
NPI:1336706795
Name:CANNON, JEANNA S
Entity Type:Individual
Prefix:
First Name:JEANNA
Middle Name:S
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 1:20571 ELLACOTT PARKWAY
Mailing Address - Street 2:SUITE 633
Mailing Address - City:WARRENSVILLE HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44128
Mailing Address - Country:US
Mailing Address - Phone:216-816-4464
Mailing Address - Fax:
Practice Address - Street 1:20571 ELLACOTT PARKWAY
Practice Address - Street 2:SUITE 633
Practice Address - City:WARRENSVILLE HTS
Practice Address - State:OH
Practice Address - Zip Code:44128
Practice Address - Country:US
Practice Address - Phone:216-816-4464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH05Medicaid