Healthcare Provider Details

I. General information

NPI: 1619729068
Provider Name (Legal Business Name): JESSIE WAGNER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 RAINBOW BLVD, MAILSTOP 4034
KANSAS CITY KS
66160
US

IV. Provider business mailing address

3901 RAINBOW BLVD, MAILSTOP 4034
KANSAS CITY KS
66160
US

V. Phone/Fax

Practice location:
  • Phone: 913-588-1908
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number94-11789
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: