Provider Demographics
NPI:1588168959
Name:MC KANNON, AMANDA ROSE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:MC KANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ROSE
Other - Last Name:MCLEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1485 SARATOGA AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129-4965
Mailing Address - Country:US
Mailing Address - Phone:877-991-0009
Mailing Address - Fax:877-207-9553
Practice Address - Street 1:1479 SARATOGA AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129-4934
Practice Address - Country:US
Practice Address - Phone:877-991-0009
Practice Address - Fax:818-241-6853
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician