Provider Demographics
NPI:1104127869
Name:CANNON, JENNIFER ANNE NIBLEY (PHD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANNE NIBLEY
Last Name:CANNON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 W 800 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-3746
Mailing Address - Country:US
Mailing Address - Phone:801-225-6246
Mailing Address - Fax:801-225-1525
Practice Address - Street 1:796 E PACIFIC DR STE B
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-3161
Practice Address - Country:US
Practice Address - Phone:801-756-1626
Practice Address - Fax:801-756-1627
Is Sole Proprietor?:No
Enumeration Date:2010-11-11
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7429787-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical