Provider Demographics
NPI:1053933176
Name:CANNON, MISTY (CDCA)
Entity type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:
Other - Last Name:DOLES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2100 BIG ROCK RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-9406
Mailing Address - Country:US
Mailing Address - Phone:740-978-0755
Mailing Address - Fax:
Practice Address - Street 1:84 E MOUND ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-1226
Practice Address - Country:US
Practice Address - Phone:740-577-8348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator