Healthcare Provider Details

I. General information

NPI: 1326487679
Provider Name (Legal Business Name): JEAN L. WAGNER LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 S. BEECH ST.
BRYAN OH
43506
US

IV. Provider business mailing address

113 S. BEECH ST.
BRYAN OH
43506
US

V. Phone/Fax

Practice location:
  • Phone: 419-633-3333
  • Fax: 419-754-2255
Mailing address:
  • Phone: 419-633-3333
  • Fax: 419-754-2255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.0025485
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.1200270
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: