Provider Demographics
NPI:1295112357
Name:JAGOS, MARK STEVEN (LMSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:STEVEN
Last Name:JAGOS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:G-4511 MILLER RD.
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507
Mailing Address - Country:US
Mailing Address - Phone:810-720-3120
Mailing Address - Fax:810-742-2920
Practice Address - Street 1:G-4511 MILLER RD.
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507
Practice Address - Country:US
Practice Address - Phone:810-720-3120
Practice Address - Fax:810-742-2920
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-28
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010751201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical