Basic Information
| Provider Information | |||||||||
| NPI: | 1215295407 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANNON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1804 EMBARCADERO RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PALO ALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 943033341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6507234000 | ||||||||
| FaxNumber: | 6504985840 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 PASTEUR DRIVE | ||||||||
| Address2: | A157A | ||||||||
| City: | STANFORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6507234000 | ||||||||
| FaxNumber: | 6504985840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2012 | ||||||||
| LastUpdateDate: | 12/22/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 21681 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | GV482Z | 01 | CA | MEDICARE PTAN | OTHER |