Provider Demographics
NPI:1902621436
Name:CANNON, JA'KYRA TANNELL (PTA)
Entity type:Individual
Prefix:
First Name:JA'KYRA
Middle Name:TANNELL
Last Name:CANNON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 CALLIOPE WAY APT 203
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-5158
Mailing Address - Country:US
Mailing Address - Phone:662-404-1023
Mailing Address - Fax:
Practice Address - Street 1:2701 CALLIOPE WAY APT 203
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-5158
Practice Address - Country:US
Practice Address - Phone:662-404-1023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty