=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851424683
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELLA K JERNIGAN LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2007
-----------------------------------------------------
Last Update Date | 03/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4898 VALLEYDALE RD SUITE B-4
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35242-4654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-538-4710
-----------------------------------------------------
Fax | 205-991-7226
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 19982
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35219-0982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-538-4710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | C1331A
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------