Healthcare Provider Details

I. General information

NPI: 1205424074
Provider Name (Legal Business Name): JENNIFER CANNON BSHS, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2021
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 MARTELLO DR
ST AUGUSTINE FL
32092-1261
US

IV. Provider business mailing address

143 MARTELLO DR
ST AUGUSTINE FL
32092-1261
US

V. Phone/Fax

Practice location:
  • Phone: 305-632-1727
  • Fax:
Mailing address:
  • Phone: 305-632-1727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA95914
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: