Basic Information
| Provider Information | |||||||||
| NPI: | 1669535464 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'CONNELL-BAGNATI | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | O'CONNELL | ||||||||
| OtherFirstName: | JACQUELINE | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 77 NEALY AVENUE | ||||||||
| Address2: | 633D MEDICAL GROUP | ||||||||
| City: | JOINT BASE LANGLEY-EUSIS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236652040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7577646840 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 45 PINE ST | ||||||||
| Address2: | 1 MDOS SGOH | ||||||||
| City: | HAMPTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236652025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7577646840 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 03/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW - 12020 | AZ | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 0904003411 | VA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.