Provider Demographics
NPI:1679264188
Name:CONCANNON, JAZMYNE MARIE
Entity type:Individual
Prefix:
First Name:JAZMYNE
Middle Name:MARIE
Last Name:CONCANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2033 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ATHOL
Mailing Address - State:MA
Mailing Address - Zip Code:01331-3535
Mailing Address - Country:US
Mailing Address - Phone:978-249-9490
Mailing Address - Fax:
Practice Address - Street 1:2033 MAIN ST
Practice Address - Street 2:
Practice Address - City:ATHOL
Practice Address - State:MA
Practice Address - Zip Code:01331-3535
Practice Address - Country:US
Practice Address - Phone:978-249-9490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health