Provider Demographics
NPI:1669299566
Name:VANDERBOGART, JENNA DIANE (MHC)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:DIANE
Last Name:VANDERBOGART
Suffix:
Gender:F
Credentials:MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 KENWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-6867
Mailing Address - Country:US
Mailing Address - Phone:518-649-6182
Mailing Address - Fax:
Practice Address - Street 1:1182 TROY SCHENECTADY RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-1001
Practice Address - Country:US
Practice Address - Phone:518-400-5180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health