MEDICARE: CANNON PSYCHOLOGICAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1134976061
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANNON PSYCHOLOGICAL LLC

Provider Business Mailing Address
First Line	:	3075 ORANGE PICKER RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-0882
Country	:	US
Telephone Number	:	352-339-6751
Fax Number	:

Provider Business Practice Location Address
First Line	:	12058 SAN JOSE BLVD STE 202
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-8669
Country	:	US
Telephone Number	:	43-738-2999
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGIST/OWNER
Name	:	DR. BRITTANY CANNON
Credential	:	PHD
Telephone Number	:	352-339-6751

Provider Enumeration Date	:	04/30/2024
Last Update Date	:	05/01/2024

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