Provider Demographics
NPI:1316744410
Name:CANNON, MESHACK JOVON I
Entity type:Individual
Prefix:
First Name:MESHACK
Middle Name:JOVON
Last Name:CANNON
Suffix:I
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11706 S 28TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68123-2724
Mailing Address - Country:US
Mailing Address - Phone:531-250-3415
Mailing Address - Fax:
Practice Address - Street 1:408 GALVIN RD N
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-4673
Practice Address - Country:US
Practice Address - Phone:402-731-1315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-26
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services