Healthcare Provider Details

I. General information

NPI: 1942362371
Provider Name (Legal Business Name): MRS. JACKIE R HAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 S JEFFERSON ST
MEXICO MO
65265-2563
US

IV. Provider business mailing address

920 S JEFFERSON ST
MEXICO MO
65265-2563
US

V. Phone/Fax

Practice location:
  • Phone: 573-581-3773
  • Fax: 573-581-4410
Mailing address:
  • Phone: 573-581-3773
  • Fax: 573-581-4410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number00797
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: