Provider Demographics
NPI: | 1003911348 |
---|---|
Name: | JEFFERSON, COWENDA SHAVONNE (MA LPC NCC CCAADC) |
Entity Type: | Individual |
Prefix: | MRS |
First Name: | COWENDA |
Middle Name: | SHAVONNE |
Last Name: | JEFFERSON |
Suffix: | |
Gender: | F |
Credentials: | MA LPC NCC CCAADC |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 103 RENAE LN |
Mailing Address - Street 2: | |
Mailing Address - City: | HOGANSVILLE |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 30230-3434 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 762-323-9693 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 103 RENAE LN |
Practice Address - Street 2: | |
Practice Address - City: | HOGANSVILLE |
Practice Address - State: | GA |
Practice Address - Zip Code: | 30230 |
Practice Address - Country: | US |
Practice Address - Phone: | 762-323-9693 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-09-13 |
Last Update Date: | 2019-05-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
GA | 229340 | 101Y00000X |
GA | C0101 | 101YA0400X |
GA | LPC006320 | 101YP2500X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional |
No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |