Healthcare Provider Details

I. General information

NPI: 1558274688
Provider Name (Legal Business Name): JAMIE LYNN WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ARAPAHOE AVE STE 14
BOULDER CO
80302-5862
US

IV. Provider business mailing address

100 ARAPAHOE AVE STE 14
BOULDER CO
80302-5862
US

V. Phone/Fax

Practice location:
  • Phone: 720-442-0946
  • Fax:
Mailing address:
  • Phone: 720-442-0946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: