Provider Demographics
NPI:1083393755
Name:BOGNER, JACLYN (MS)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:BOGNER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 BENDIX AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-5877
Mailing Address - Country:US
Mailing Address - Phone:207-831-8388
Mailing Address - Fax:
Practice Address - Street 1:1 SERENITY LN
Practice Address - Street 2:
Practice Address - City:COBURG
Practice Address - State:OR
Practice Address - Zip Code:97408-9350
Practice Address - Country:US
Practice Address - Phone:541-687-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health