Provider Demographics
NPI:1366849473
Name:WAGNER, JACQUELINE NICOLE (MLSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MLSW
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:NICOLE
Other - Last Name:SCHNECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1613 M 139
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-5748
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1613 M 139
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-5748
Practice Address - Country:US
Practice Address - Phone:269-934-0716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-04
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801097554104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker