Basic Information
| Provider Information | |||||||||
| NPI: | 1558536490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANNON | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | DANETTE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 RIVERPLACE BLVD 620 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322071803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043966620 | ||||||||
| FaxNumber: | 9043966528 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 RIVERPLACE BLVD 620 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322071803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043966620 | ||||||||
| FaxNumber: | 9043966528 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2008 | ||||||||
| LastUpdateDate: | 07/29/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | ARNP9169833 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 0031120-00 | 05 | FL | MEDICAID | 0004553-00 | 05 | FL | MEDICAID | 580304754A | 05 | GA | MEDICAID | 003104660A | 05 | GA | MEDICAID | ARNP9169833 | 01 | FL | FLORIDA BOARD OF NUSING LICENSE # | OTHER |