Provider Demographics
NPI:1972728657
Name:VAN WAGONER, JANE ELLEN (MFT)
Entity type:Individual
Prefix:MRS
First Name:JANE
Middle Name:ELLEN
Last Name:VAN WAGONER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 BREA BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-4123
Mailing Address - Country:US
Mailing Address - Phone:714-738-1733
Mailing Address - Fax:714-996-1013
Practice Address - Street 1:1370 BREA BLVD STE 120
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-4123
Practice Address - Country:US
Practice Address - Phone:714-738-1733
Practice Address - Fax:714-996-1013
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMR022526106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist