Provider Demographics
NPI:1538404090
Name:JAGO, ELIZABETH ANN (PSYD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ANN
Last Name:JAGO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 W 9TH ST
Mailing Address - Street 2:SUITE 1B-2
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-8905
Mailing Address - Country:US
Mailing Address - Phone:347-927-1657
Mailing Address - Fax:
Practice Address - Street 1:12 W 9TH ST
Practice Address - Street 2:SUITE 1B-2
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8905
Practice Address - Country:US
Practice Address - Phone:347-927-1657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-10
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008475103TC0700X
NY021075103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical