Provider Demographics
NPI:1790994598
Name:BAGWELL, JENNIFER MILLER (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:MILLER
Last Name:BAGWELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:JANE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:4440 PGA BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-6540
Mailing Address - Country:US
Mailing Address - Phone:954-465-6988
Mailing Address - Fax:
Practice Address - Street 1:4440 PGA BLVD STE 202
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410
Practice Address - Country:US
Practice Address - Phone:954-465-6988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW63661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ021XOtherBCBS