Provider Demographics
NPI:1386043537
Name:COBURN, SHANICE (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANICE
Middle Name:
Last Name:COBURN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-4211
Mailing Address - Country:US
Mailing Address - Phone:501-982-5402
Mailing Address - Fax:
Practice Address - Street 1:323 CENTER ST STE 1420
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72201-2651
Practice Address - Country:US
Practice Address - Phone:501-474-6131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-13
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
AR7338-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health