Provider Demographics
NPI:1568626505
Name:DAVENPORT, JANNA LYNN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JANNA
Middle Name:LYNN
Last Name:DAVENPORT
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 1:704 MONTY CIR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-3297
Mailing Address - Country:US
Mailing Address - Phone:305-962-4849
Mailing Address - Fax:
Practice Address - Street 1:1514 W 23RD ST
Practice Address - Street 2:SUITE A-6
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-2905
Practice Address - Country:US
Practice Address - Phone:305-962-4849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-17
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW61601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12201351OtherCAQH
FLEC046ZOtherMEDICARE
FL762281300Medicaid