Provider Demographics
NPI:1790531374
Name:CANN, JAMAAL EDWARD
Entity type:Individual
Prefix:
First Name:JAMAAL
Middle Name:EDWARD
Last Name:CANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3026 MARLBOROUGH ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-2536
Mailing Address - Country:US
Mailing Address - Phone:586-339-7110
Mailing Address - Fax:
Practice Address - Street 1:4203 18TH ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-2515
Practice Address - Country:US
Practice Address - Phone:586-339-7110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver