MEDICARE: MS. JEANIE WAGENER MS, CCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	LL00001505	WA

General Provider Information

NPI Number	:	1053302299
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JEANIE WAGENER MS, CCC

Provider Business Mailing Address
First Line	:	1010 WASHINGTON ST
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98660-3167
Country	:	US
Telephone Number	:	360-699-6374
Fax Number	:

Provider Business Practice Location Address
First Line	:	1010 WASHINGTON ST
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98660-3167
Country	:	US
Telephone Number	:	360-699-6374
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2005
Last Update Date	:	07/08/2007

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