Provider Demographics
NPI:1356910624
Name:CANNON, JACOB (DPT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:CANNON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 MARVEL CT
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-4052
Mailing Address - Country:US
Mailing Address - Phone:410-822-4613
Mailing Address - Fax:410-822-6534
Practice Address - Street 1:406 MARVEL CT
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-4052
Practice Address - Country:US
Practice Address - Phone:410-822-4613
Practice Address - Fax:410-822-6534
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD28475208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation