Provider Demographics
NPI:1093012031
Name:JEFFERSON, SHANNA AMANDA (MSW,CFSW,LCSW)
Entity Type:Individual
Prefix:MISS
First Name:SHANNA
Middle Name:AMANDA
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:MSW,CFSW,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13273
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27709-3273
Mailing Address - Country:US
Mailing Address - Phone:919-794-5284
Mailing Address - Fax:866-923-0754
Practice Address - Street 1:2530 MERIDIAN PKWY STE 300
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-5273
Practice Address - Country:US
Practice Address - Phone:919-794-5284
Practice Address - Fax:866-923-0754
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-25
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0081851041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6009279Medicaid
NC6009279Medicaid