Provider Demographics
NPI:1679042535
Name:IANNOTTI, AMANDA ROSE (LMHC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:IANNOTTI
Suffix:
Gender:F
Credentials:LMHC
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 19249
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-9249
Mailing Address - Country:US
Mailing Address - Phone:904-743-1883
Mailing Address - Fax:904-743-5309
Practice Address - Street 1:3333 W 20TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-1703
Practice Address - Country:US
Practice Address - Phone:904-695-9145
Practice Address - Fax:904-695-2465
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-20
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH16379101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health