Basic Information
| Provider Information | |||||||||
| NPI: | 1124516109 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ACMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 330 | ||||||||
| Address2: | |||||||||
| City: | MAGNA | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840440330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019904300 | ||||||||
| FaxNumber: | 8019672127 | ||||||||
| Practice Location | |||||||||
| Address1: | 3509 W 4700 S | ||||||||
| Address2: | |||||||||
| City: | TAYLORSVILLE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841292846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019904300 | ||||||||
| FaxNumber: | 8019672127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2018 | ||||||||
| LastUpdateDate: | 02/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 8663400-6009 | UT | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.