Provider Demographics
NPI:1417054172
Name:WAGNER, JO-ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:JO-ANN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 JAMESTOWN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-3382
Mailing Address - Country:US
Mailing Address - Phone:757-229-7927
Mailing Address - Fax:757-253-8891
Practice Address - Street 1:1318 JAMESTOWN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-3382
Practice Address - Country:US
Practice Address - Phone:757-229-7927
Practice Address - Fax:757-253-8891
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040008591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA000249OtherVALUE OPTIONS
VA13467OtherCIGNA
VA086720OtherOPTIMA
VA8903913Medicaid
VA380403OtherANTHEM
VA323507OtherMHN
VA339165OtherMAMSI/ALLIANCE
VA323507OtherMHN