Basic Information
| Provider Information | |||||||||
| NPI: | 1609012434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PINKHAM | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | JAYNE | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1209 ILLINI DR | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622693548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185804769 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 310 W LOSEY ST | ||||||||
| Address2: | |||||||||
| City: | SCOTT AFB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622255250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182567203 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2008 | ||||||||
| LastUpdateDate: | 04/24/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 2008033011 | MO | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.