Healthcare Provider Details

I. General information

NPI: 1003911348
Provider Name (Legal Business Name): COWENDA SHAVONNE JEFFERSON MA LPC NCC CCAADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 05/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 RENAE LN
HOGANSVILLE GA
30230
US

IV. Provider business mailing address

103 RENAE LN
HOGANSVILLE GA
30230-3434
US

V. Phone/Fax

Practice location:
  • Phone: 762-323-9693
  • Fax:
Mailing address:
  • Phone: 762-323-9693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number229340
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC0101
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC006320
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: