Provider Demographics
NPI:1063133361
Name:WAGGONER, JENNIFER MARIE (C8432 LCSW)
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:MARIE
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:C8432 LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7714 MOANALUA WAY
Mailing Address - Street 2:
Mailing Address - City:DIAMONDHEAD
Mailing Address - State:MS
Mailing Address - Zip Code:39525-3740
Mailing Address - Country:US
Mailing Address - Phone:228-305-0063
Mailing Address - Fax:
Practice Address - Street 1:7714 MOANALUA WAY
Practice Address - Street 2:
Practice Address - City:DIAMONDHEAD
Practice Address - State:MS
Practice Address - Zip Code:39525-3740
Practice Address - Country:US
Practice Address - Phone:228-305-0063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC84321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical