Healthcare Provider Details

I. General information

NPI: 1427445279
Provider Name (Legal Business Name): JENNIFER WAGNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2015
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 NAUTICAL DR STE 2
CLOVER SC
29710-8182
US

IV. Provider business mailing address

534 NAUTICAL DR STE 2
CLOVER SC
29710-8182
US

V. Phone/Fax

Practice location:
  • Phone: 803-619-4121
  • Fax: 803-965-3119
Mailing address:
  • Phone: 803-619-4121
  • Fax: 803-965-3119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2026-00005
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number96214
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number57147
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: