Provider Demographics
NPI:1386979185
Name:VAN WAGNER, JENNA (MS)
Entity type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:
Last Name:VAN WAGNER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:JENNA
Other - Middle Name:
Other - Last Name:FLOWERREE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:5240 DAHLIA DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-1407
Mailing Address - Country:US
Mailing Address - Phone:310-428-3768
Mailing Address - Fax:
Practice Address - Street 1:5240 DAHLIA DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-1407
Practice Address - Country:US
Practice Address - Phone:310-428-3768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-12
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CALMFT77695106H00000X
CA59669106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health