Provider Demographics
NPI:1366091092
Name:BAGNALL, JANE R (CDCA)
Entity type:Individual
Prefix:MRS
First Name:JANE
Middle Name:R
Last Name:BAGNALL
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-1189
Mailing Address - Country:US
Mailing Address - Phone:440-205-2670
Mailing Address - Fax:440-285-8543
Practice Address - Street 1:209 CENTER ST
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-1189
Practice Address - Country:US
Practice Address - Phone:440-205-2670
Practice Address - Fax:440-285-8543
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0001422175T00000X
OHCDCA181590101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist