Basic Information
| Provider Information | |||||||||
| NPI: | 1003370545 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10711 JUSTIN CEMETERY RD LOT 264 | ||||||||
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| City: | JUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762478032 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 120 MEADOW VIEW DR | ||||||||
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| City: | JUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762479639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406482731 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2019 | ||||||||
| LastUpdateDate: | 01/29/2019 | ||||||||
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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 | 224Z00000X | 212402 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.