Healthcare Provider Details

I. General information

NPI: 1750725008
Provider Name (Legal Business Name): JENNIFER LEIGH CANNON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2013
Last Update Date: 08/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MED TECH PKWY
JOHNSON CITY TN
37604-2277
US

IV. Provider business mailing address

119 BOONE RIDGE DR STE 201
JOHNSON CITY TN
37615-8000
US

V. Phone/Fax

Practice location:
  • Phone: 423-282-1480
  • Fax: 423-928-1353
Mailing address:
  • Phone: 423-743-6135
  • Fax: 423-743-0035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17519
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: