Provider Demographics
NPI:1013124247
Name:SHANKS, JENNIFER (LCSW, LCADC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SHANKS
Suffix:
Gender:F
Credentials:LCSW, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 BROADFIELDS DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4341
Mailing Address - Country:US
Mailing Address - Phone:502-548-5647
Mailing Address - Fax:
Practice Address - Street 1:161 SAINT MATTHEWS AVE STE 18
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-3145
Practice Address - Country:US
Practice Address - Phone:502-548-5647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY164585101YA0400X
KY34371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty