Basic Information
| Provider Information | |||||||||
| NPI: | 1144549213 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANNON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | P.T, | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1060 THORNRIDGE CIR | ||||||||
| Address2: | |||||||||
| City: | ARGYLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762262525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9405950411 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2535 W OAK ST | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762012331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403821577 | ||||||||
| FaxNumber: | 9403875471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2010 | ||||||||
| LastUpdateDate: | 09/23/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1195568 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 854T74 | 01 | TX | BCBS ORTHOTEXAS | OTHER | P00954309 | 01 | TX | RAILROAD MEDICARE | OTHER |