Provider Demographics
NPI:1578272316
Name:VAN WAGENEN, JILLIAN QUINN (BS; CADCR)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:QUINN
Last Name:VAN WAGENEN
Suffix:
Gender:F
Credentials:BS; CADCR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 TARBERT DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-5052
Mailing Address - Country:US
Mailing Address - Phone:919-397-1754
Mailing Address - Fax:
Practice Address - Street 1:128 QUADE DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-7400
Practice Address - Country:US
Practice Address - Phone:919-651-8349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2022-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29047101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)