Provider Demographics
NPI:1386130524
Name:WAGSTAFF, JENNY F (PHD, LPC-S, NCC, ACS)
Entity type:Individual
Prefix:DR
First Name:JENNY
Middle Name:F
Last Name:WAGSTAFF
Suffix:
Gender:F
Credentials:PHD, LPC-S, NCC, ACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:BUIES CREEK
Mailing Address - State:NC
Mailing Address - Zip Code:27506-0369
Mailing Address - Country:US
Mailing Address - Phone:910-893-1633
Mailing Address - Fax:
Practice Address - Street 1:817 W FRONT ST
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-9735
Practice Address - Country:US
Practice Address - Phone:910-814-2197
Practice Address - Fax:910-814-2167
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005095101YP2500X
NCS13702101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional