Provider Demographics
NPI:1104874445
Name:CANNON, JEAN S (PSYD)
Entity type:Individual
Prefix:DR
First Name:JEAN
Middle Name:S
Last Name:CANNON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:ELIZABETH
Other - Last Name:STEVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1681 CROWN AVE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-6303
Mailing Address - Country:US
Mailing Address - Phone:717-393-9388
Mailing Address - Fax:717-393-9389
Practice Address - Street 1:1681 CROWN AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-6303
Practice Address - Country:US
Practice Address - Phone:717-393-9388
Practice Address - Fax:717-393-9389
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015850103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101535870-0001Medicaid
CA1850139OtherHIGHMARK BLUE SHIEL
CA1850139OtherHIGHMARK BLUE SHIEL
1003358Medicare PIN
PAQ68286Medicare UPIN