Provider Demographics
NPI:1417490160
Name:KANWISCHER-JAGIM, KATRINA
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:KANWISCHER-JAGIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 CAROLINA DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-6412
Mailing Address - Country:US
Mailing Address - Phone:573-316-1927
Mailing Address - Fax:
Practice Address - Street 1:117 S LEXINGTON ST STE 100
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-2444
Practice Address - Country:US
Practice Address - Phone:573-316-1927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-29
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2016-036A106H00000X
174400000X
ND2019-071106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No174400000XOther Service ProvidersSpecialist