Provider Demographics
NPI:1194230599
Name:BOGDANOV, JACQUELYN (PSYD)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:
Last Name:BOGDANOV
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9302 W BLUEMOUND RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4449
Mailing Address - Country:US
Mailing Address - Phone:262-289-8379
Mailing Address - Fax:
Practice Address - Street 1:9302 W BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4449
Practice Address - Country:US
Practice Address - Phone:262-289-8379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-06
Last Update Date:2025-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3661-57103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical