Provider Demographics
NPI:1871057851
Name:JAGDON, DENNIS (SRNA)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:JAGDON
Suffix:
Gender:M
Credentials:SRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 W ARLINGTON BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-3770
Mailing Address - Country:US
Mailing Address - Phone:252-752-2140
Mailing Address - Fax:252-689-6502
Practice Address - Street 1:1550 UNION RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5522
Practice Address - Country:US
Practice Address - Phone:704-864-8772
Practice Address - Fax:704-866-7853
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC141259390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program