Healthcare Provider Details

I. General information

NPI: 1093117731
Provider Name (Legal Business Name): JENNIFER ANN WAGNER M.A. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2014
Last Update Date: 09/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 MISSOURI AVE
JEFFERSONVILLE IN
47130-3082
US

IV. Provider business mailing address

7607 ASHBY LANDINGS DR UNIT 204
LOUISVILLE KY
40272-7727
US

V. Phone/Fax

Practice location:
  • Phone: 219-218-7214
  • Fax:
Mailing address:
  • Phone: 219-218-7214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22005992A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: