Provider Demographics
NPI:1447783642
Name:KANNEN, JEFFREY (DO)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:KANNEN
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5901 E FOWLER AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33617-2305
Mailing Address - Country:US
Mailing Address - Phone:813-978-9700
Mailing Address - Fax:
Practice Address - Street 1:5901 E FOWLER AVE STE 100
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33617-2305
Practice Address - Country:US
Practice Address - Phone:813-978-9700
Practice Address - Fax:813-558-6190
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-05
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOS16865207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program