Healthcare Provider Details

I. General information

NPI: 1093610354
Provider Name (Legal Business Name): JESSE MARIE DI CARLO-WAGNER
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 MURRAY DR
EL CAJON CA
92020-5664
US

IV. Provider business mailing address

2337 COMMONWEALTH AVE
SAN DIEGO CA
92104-5322
US

V. Phone/Fax

Practice location:
  • Phone: 619-668-6141
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number39356
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: