MEDICARE: MR. JAMES KENNEDY CANNON LISW-S, LICDC-CS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	913109	OH
2	1041C0700X	Clinical Social Worker	I 1000338	OH

General Provider Information

NPI Number	:	1932557147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES KENNEDY CANNON LISW-S, LICDC-CS

Provider Business Mailing Address
First Line	:	310 TROY ST
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45404-1858
Country	:	US
Telephone Number	:	937-463-2955
Fax Number	:	937-531-7019

Provider Business Practice Location Address
First Line	:	310 TROY ST
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45404-1858
Country	:	US
Telephone Number	:	937-463-2955
Fax Number	:	937-531-7019

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2016
Last Update Date	:	05/27/2016

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