Healthcare Provider Details

I. General information

NPI: 1023273778
Provider Name (Legal Business Name): JESSICA CANNON LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA PANAICH

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 02/24/2023
Certification Date: 02/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 KENDALL CT
WESTFIELD IN
46074-8579
US

IV. Provider business mailing address

379 BOLIN CT
CARMEL IN
46032-8532
US

V. Phone/Fax

Practice location:
  • Phone: 804-247-5640
  • Fax: 317-836-1520
Mailing address:
  • Phone: 804-247-5640
  • Fax: 317-836-1520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number39003442A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: