Provider Demographics
NPI:1699212779
Name:CANNON, JENNIFER (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CANNON
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 HOSPITAL DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4568
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:380 9TH ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-9470
Practice Address - Country:US
Practice Address - Phone:541-997-7134
Practice Address - Fax:541-902-1320
Is Sole Proprietor?:No
Enumeration Date:2017-01-26
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11485363L00000X
OR201801167NP-PP363L00000X
MTNUR-APRN-LIC-180218363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner