Healthcare Provider Details

I. General information

NPI: 1619790003
Provider Name (Legal Business Name): JACOB WAGGONER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2043 W BELMONT AVE STE 1
CHICAGO IL
60618-6796
US

IV. Provider business mailing address

1344 W LUNT AVE APT 303
CHICAGO IL
60626-3072
US

V. Phone/Fax

Practice location:
  • Phone: 312-324-4502
  • Fax:
Mailing address:
  • Phone: 248-895-2933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: