Healthcare Provider Details

I. General information

NPI: 1730680562
Provider Name (Legal Business Name): JENNIE HULL-CANNON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 02/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 NEWTOWN PIKE BLDG 1
LEXINGTON KY
40511-1277
US

IV. Provider business mailing address

1351 NEWTOWN PIKE BLDG 1
LEXINGTON KY
40511-1277
US

V. Phone/Fax

Practice location:
  • Phone: 859-253-1686
  • Fax:
Mailing address:
  • Phone: 859-253-1686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number252544
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: