Basic Information
| Provider Information | |||||||||
| NPI: | 1679042535 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IANNOTTI | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19249 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322459249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047431883 | ||||||||
| FaxNumber: | 9047435309 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 W 20TH ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322541703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046959145 | ||||||||
| FaxNumber: | 9046952465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2018 | ||||||||
| LastUpdateDate: | 11/20/2018 | ||||||||
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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 | 101YM0800X | MH16379 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.