Provider Demographics
NPI:1700903143
Name:CANNON, JOHN T (PHD LMHP LADC)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:T
Last Name:CANNON
Suffix:
Gender:M
Credentials:PHD LMHP LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16305 DECATUR CIR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68118-2418
Mailing Address - Country:US
Mailing Address - Phone:402-660-8049
Mailing Address - Fax:
Practice Address - Street 1:1045 N 115TH ST STE 205
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-4422
Practice Address - Country:US
Practice Address - Phone:402-660-8049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE372101YA0400X
NE1535101YM0800X
IA00829101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)