Provider Demographics
NPI:1043605942
Name:JENKINS, AMANDA (LCPC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:JENKINS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:BROUGHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:425 HOME AVE APT 3E
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-3723
Mailing Address - Country:US
Mailing Address - Phone:508-362-0661
Mailing Address - Fax:
Practice Address - Street 1:7300 W COLLEGE DR STE 203
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1183
Practice Address - Country:US
Practice Address - Phone:708-448-7848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180009382101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health