Provider Demographics
NPI:1932557147
Name:CANNON, JAMES KENNEDY (LISW-S, LICDC-CS)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:KENNEDY
Last Name:CANNON
Suffix:
Gender:M
Credentials:LISW-S, LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 TROY ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45404-1858
Mailing Address - Country:US
Mailing Address - Phone:937-463-2955
Mailing Address - Fax:937-531-7019
Practice Address - Street 1:310 TROY ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45404-1858
Practice Address - Country:US
Practice Address - Phone:937-463-2955
Practice Address - Fax:937-531-7019
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH913109101YA0400X
OHI 10003381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)