Provider Demographics
NPI:1629893730
Name:WAGAR, JIA (LPCC)
Entity type:Individual
Prefix:
First Name:JIA
Middle Name:
Last Name:WAGAR
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 BEMIDJI AVE N STE 200
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-3056
Mailing Address - Country:US
Mailing Address - Phone:218-308-2423
Mailing Address - Fax:
Practice Address - Street 1:800 BEMIDJI AVE N STE 200
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3056
Practice Address - Country:US
Practice Address - Phone:218-308-2423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-22
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3913101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional