Provider Demographics
NPI:1699004390
Name:JAGGER, BRENDA G (MS, LPC)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:G
Last Name:JAGGER
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 1/2 W MAIN ST STE D
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-6316
Mailing Address - Country:US
Mailing Address - Phone:580-220-7245
Mailing Address - Fax:
Practice Address - Street 1:220 1/2 W MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-6316
Practice Address - Country:US
Practice Address - Phone:580-220-7245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-09
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4352101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional