Provider Demographics
NPI:1861736878
Name:JAGUSCH, ANDREA SUZANNE (LICSW)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:SUZANNE
Last Name:JAGUSCH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7023 49TH ST N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-2650
Mailing Address - Country:US
Mailing Address - Phone:507-398-3603
Mailing Address - Fax:
Practice Address - Street 1:1575 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1126
Practice Address - Country:US
Practice Address - Phone:651-326-7662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN198811041C0700X
MN4650891041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical