Healthcare Provider Details

I. General information

NPI: 1922051424
Provider Name (Legal Business Name): JENIFER M CANNON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: JENIFER M JOHNSON M.D.

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9701 LANDMARK PARKWAY DR SUITE 207
SAINT LOUIS MO
63127-1665
US

IV. Provider business mailing address

12639 OLD TESSON RD SUITE 115
SAINT LOUIS MO
63128-2786
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-4802
  • Fax: 314-849-8721
Mailing address:
  • Phone: 314-849-0311
  • Fax: 314-849-4423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberR8J94
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: