MEDICARE: JESSICA SHIRLEY WAGONER MS/OT

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	225X00000X	Occupational Therapist	P142944	NY

General Provider Information

NPI Number	:	1871427351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA SHIRLEY WAGONER MS/OT

Provider Business Mailing Address
First Line	:	1536 CRESCENT RD
Second Line	:
City	:	CLIFTON PARK
State	:	NY
Zip	:	12065-7729
Country	:	US
Telephone Number	:	518-288-7054
Fax Number	:

Provider Business Practice Location Address
First Line	:	1536 CRESCENT RD
Second Line	:
City	:	CLIFTON PARK
State	:	NY
Zip	:	12065-7729
Country	:	US
Telephone Number	:	518-288-7054
Fax Number	:

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

Provider Enumeration Date	:	06/10/2026
Last Update Date	:	06/10/2026

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