Provider Demographics
NPI:1538676630
Name:WAGGONER, STEPHANIE N (LMHC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:N
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:N
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9957 MOORINGS DR STE 302
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-2415
Mailing Address - Country:US
Mailing Address - Phone:888-793-2304
Mailing Address - Fax:888-793-2304
Practice Address - Street 1:9957 MOORINGS DR STE 302
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-2415
Practice Address - Country:US
Practice Address - Phone:888-793-2304
Practice Address - Fax:888-793-2304
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH20071101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health