Provider Demographics
NPI:1891393989
Name:WAGONER, ANDREW JACOB (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:JACOB
Last Name:WAGONER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3452
Mailing Address - Country:US
Mailing Address - Phone:812-913-5462
Mailing Address - Fax:
Practice Address - Street 1:460 SPRING ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3452
Practice Address - Country:US
Practice Address - Phone:812-913-5462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-12
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical