Provider Demographics
NPI:1003500513
Name:ZAGONE, JACQUELYN REGINA (PMHNP)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:REGINA
Last Name:ZAGONE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 W WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:WENONAH
Mailing Address - State:NJ
Mailing Address - Zip Code:08090-1850
Mailing Address - Country:US
Mailing Address - Phone:856-571-2139
Mailing Address - Fax:
Practice Address - Street 1:777 ROUTE 70 E STE G101
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2548
Practice Address - Country:US
Practice Address - Phone:800-413-8020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ14846000363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health