Provider Demographics
NPI:1669867446
Name:HAGAN, JESSICA (MA, LPC, NCC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HAGAN
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2563 S VAL VISTA DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-1804
Mailing Address - Country:US
Mailing Address - Phone:480-448-1076
Mailing Address - Fax:480-646-8811
Practice Address - Street 1:2563 S VAL VISTA DR
Practice Address - Street 2:SUITE 108
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-1804
Practice Address - Country:US
Practice Address - Phone:480-448-1076
Practice Address - Fax:480-646-8811
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-13921101YM0800X
AZLPC-15686101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health