Healthcare Provider Details

I. General information

NPI: 1548870868
Provider Name (Legal Business Name): MANILLA SHANTA JENKINS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2020
Last Update Date: 08/01/2020
Certification Date: 08/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 WALL ST
MONTGOMERY AL
36106-2924
US

IV. Provider business mailing address

PO BOX 240912
MONTGOMERY AL
36124-0912
US

V. Phone/Fax

Practice location:
  • Phone: 334-247-3900
  • Fax: 334-247-3902
Mailing address:
  • Phone: 334-247-3900
  • Fax: 334-247-3902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3864
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: