Provider Demographics
NPI:1336896034
Name:BAGWELL, JACQUELINE (COUNSELOR)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BAGWELL
Suffix:
Gender:F
Credentials:COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 DELAWARE AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-2016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:255 DELAWARE AVE FL 3
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-2016
Practice Address - Country:US
Practice Address - Phone:716-842-0440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)