Healthcare Provider Details

I. General information

NPI: 1134611254
Provider Name (Legal Business Name): JA'REALLE MONET CANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8326 MAIN ST BLDG 3
HOUMA LA
70363-4871
US

IV. Provider business mailing address

8326 MAIN ST BLDG 3
HOUMA LA
70363-4871
US

V. Phone/Fax

Practice location:
  • Phone: 985-868-2620
  • Fax: 985-868-8474
Mailing address:
  • Phone: 985-868-2620
  • Fax: 985-868-8474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number19635
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: