Provider Demographics
NPI:1124716071
Name:CANNON, TANARRIS JAMON JR
Entity type:Individual
Prefix:MR
First Name:TANARRIS
Middle Name:JAMON
Last Name:CANNON
Suffix:JR
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 1:214 GRACE AVE
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:FL
Mailing Address - Zip Code:33838-4564
Mailing Address - Country:US
Mailing Address - Phone:863-307-6548
Mailing Address - Fax:
Practice Address - Street 1:214 GRACE AVE
Practice Address - Street 2:
Practice Address - City:DUNDEE
Practice Address - State:FL
Practice Address - Zip Code:33838-4564
Practice Address - Country:US
Practice Address - Phone:863-307-6548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-28
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23-291721106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician