Provider Demographics
NPI:1669535464
Name:O'CONNELL-BAGNATI, JACQUELINE ANN (LCSW)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:ANN
Last Name:O'CONNELL-BAGNATI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:ANN
Other - Last Name:O'CONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:77 NEALY AVENUE
Mailing Address - Street 2:633D MEDICAL GROUP
Mailing Address - City:JOINT BASE LANGLEY-EUSIS
Mailing Address - State:VA
Mailing Address - Zip Code:23665-2040
Mailing Address - Country:US
Mailing Address - Phone:757-764-6840
Mailing Address - Fax:
Practice Address - Street 1:45 PINE ST
Practice Address - Street 2:1 MDOS SGOH
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23665-2025
Practice Address - Country:US
Practice Address - Phone:757-764-6840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW - 120201041C0700X
VA09040034111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical