Provider Demographics
NPI:1275771461
Name:SHANKS, AMANDA JERNIGAN (LPC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JERNIGAN
Last Name:SHANKS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MICHELLE
Other - Last Name:JERNIGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6845 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3363
Mailing Address - Country:US
Mailing Address - Phone:704-995-2365
Mailing Address - Fax:
Practice Address - Street 1:6845 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3363
Practice Address - Country:US
Practice Address - Phone:704-995-2365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-27
Last Update Date:2012-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor