Provider Demographics
NPI:1336329291
Name:WALLACE-JACKSON, PANORA ZENIK (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:PANORA
Middle Name:ZENIK
Last Name:WALLACE-JACKSON
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:MS
Other - First Name:PANORA
Other - Middle Name:ZENIK
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA,LPC
Mailing Address - Street 1:576 W CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29550-5412
Mailing Address - Country:US
Mailing Address - Phone:843-309-9340
Mailing Address - Fax:843-309-9341
Practice Address - Street 1:576 W CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-5412
Practice Address - Country:US
Practice Address - Phone:843-309-9340
Practice Address - Fax:843-309-9341
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-08
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3343Medicare PIN
SC405127Medicaid