Healthcare Provider Details

I. General information

NPI: 1003736984
Provider Name (Legal Business Name): JENNIFER M WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MIAMI VALLEY DR
CENTERVILLE OH
45459-4774
US

IV. Provider business mailing address

2862 ROCHESTER AVE
FAIRFIELD TOWNSHIP OH
45011-0515
US

V. Phone/Fax

Practice location:
  • Phone: 937-438-2400
  • Fax:
Mailing address:
  • Phone: 513-255-4020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN.CNP.0042761
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: