MEDICARE: MRS. COWENDA SHAVONNE JEFFERSON MA LPC NCC CCAADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	229340	GA
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	C0101	GA
3	101YP2500X	Professional Counselor	LPC006320	GA

General Provider Information

NPI Number	:	1003911348
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. COWENDA SHAVONNE JEFFERSON MA LPC NCC CCAADC

Provider Business Mailing Address
First Line	:	103 RENAE LN
Second Line	:
City	:	HOGANSVILLE
State	:	GA
Zip	:	30230-3434
Country	:	US
Telephone Number	:	762-323-9693
Fax Number	:

Provider Business Practice Location Address
First Line	:	103 RENAE LN
Second Line	:
City	:	HOGANSVILLE
State	:	GA
Zip	:	30230
Country	:	US
Telephone Number	:	762-323-9693
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	05/20/2019

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