Provider Demographics
NPI:1629101167
Name:WAGNER, JEANNE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JEANNE
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 1:15 WYSTERIA WAY
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-1637
Mailing Address - Country:US
Mailing Address - Phone:919-933-8840
Mailing Address - Fax:
Practice Address - Street 1:15 WYSTERIA WAY
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-1637
Practice Address - Country:US
Practice Address - Phone:919-933-8840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0025371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical