Organization
JERRY WAGGONER LPC L.L.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JERRY WAGGONER LPC (SOLE MEMBER)
(636) 633-1980
Entity
Organization
Contact information
Practice address
1000 LAKE SAINT LOUIS BLVD STE 260, LAKE SAINT LOUIS, MO 63367-2924
(314) 994-9344
Mailing address
36 S LAKE DR, HILLSBORO, MO 63050-4424
(636) 633-1980
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
001573
MO
Other
Enumeration date
10/21/2011
Last updated
10/21/2011
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