Healthcare Provider Details

I. General information

NPI: 1093610255
Provider Name (Legal Business Name): JAY JOHN WAGENER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

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

67 W DAYTON ST
PASADENA CA
91105-2001
US

IV. Provider business mailing address

67 W DAYTON ST
PASADENA CA
91105-2001
US

V. Phone/Fax

Practice location:
  • Phone: 626-825-8782
  • Fax:
Mailing address:
  • Phone: 626-825-8782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY8453
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: