Provider Demographics
NPI:1366955403
Name:HANKS, JACQUELINE (EDS, LMFT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:HANKS
Suffix:
Gender:F
Credentials:EDS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 WHITBY RD
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-2435
Mailing Address - Country:US
Mailing Address - Phone:803-338-5059
Mailing Address - Fax:803-638-4890
Practice Address - Street 1:125 ALPINE CIR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-6385
Practice Address - Country:US
Practice Address - Phone:803-779-3548
Practice Address - Fax:803-799-7055
Is Sole Proprietor?:No
Enumeration Date:2017-11-12
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6984101Y00000X, 101YM0800X, 101YP2500X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health