Provider Demographics
NPI:1356755268
Name:FUENTES, JACQUELINE PAGNOTTA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:PAGNOTTA
Last Name:FUENTES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1949 CASTLE PINES DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-8466
Mailing Address - Country:US
Mailing Address - Phone:845-527-7720
Mailing Address - Fax:
Practice Address - Street 1:1949 CASTLE PINES DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-8466
Practice Address - Country:US
Practice Address - Phone:845-527-7720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0086661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical