Provider Demographics
NPI:1003911348
Name:JEFFERSON, COWENDA SHAVONNE (MA LPC NCC CCAADC)
Entity type:Individual
Prefix:MRS
First Name:COWENDA
Middle Name:SHAVONNE
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:MA LPC NCC CCAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 RENAE LN
Mailing Address - Street 2:
Mailing Address - City:HOGANSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30230-3434
Mailing Address - Country:US
Mailing Address - Phone:762-323-9693
Mailing Address - Fax:
Practice Address - Street 1:103 RENAE LN
Practice Address - Street 2:
Practice Address - City:HOGANSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30230
Practice Address - Country:US
Practice Address - Phone:762-323-9693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA229340101Y00000X
GAC0101101YA0400X
GALPC006320101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)