Provider Demographics
NPI:1669177119
Name:HAGAN, JENNIFER D (MA LADC LPCC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:D
Last Name:HAGAN
Suffix:
Gender:F
Credentials:MA LADC LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 COLETTE PL
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-2554
Mailing Address - Country:US
Mailing Address - Phone:651-690-0451
Mailing Address - Fax:
Practice Address - Street 1:1132 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-1512
Practice Address - Country:US
Practice Address - Phone:612-902-6009
Practice Address - Fax:612-236-1701
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3565101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health