Provider Demographics
NPI:1447303482
Name:SHIVERS-ROANE, JACQUELYN BONITA (MA, LPC)
Entity type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:BONITA
Last Name:SHIVERS-ROANE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:MRS
Other - First Name:JACQUELYN
Other - Middle Name:BONITA
Other - Last Name:ARRINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:USAG-GIESSEN
Mailing Address - Street 2:CMR 453 BOX 1789
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09074
Mailing Address - Country:DE
Mailing Address - Phone:01149603-181-1710
Mailing Address - Fax:
Practice Address - Street 1:USAG-GIESSEN
Practice Address - Street 2:CMR 453 BOX 1789
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09074
Practice Address - Country:DE
Practice Address - Phone:01149603-181-1710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPRC1193101YP2500X
PAICADC 15184101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)