Provider Demographics
NPI:1982093522
Name:WAGONER, JEREMY MICHAEL (LCSW)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:MICHAEL
Last Name:WAGONER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 ANDREA ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3382
Mailing Address - Country:US
Mailing Address - Phone:270-904-2260
Mailing Address - Fax:270-781-9680
Practice Address - Street 1:1300 ANDREA ST
Practice Address - Street 2:SUITE 205
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3382
Practice Address - Country:US
Practice Address - Phone:270-904-2260
Practice Address - Fax:270-781-9680
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical