Healthcare Provider Details

I. General information

NPI: 1679477681
Provider Name (Legal Business Name): JAYDEE ANN WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 S NEDDERMAN DRIVE BOX 19407
ARLINGTON TX
76019-0001
US

IV. Provider business mailing address

411 S NEDDERMAN DRIVE BOX 19407
ARLINGTON TX
76019-0001
US

V. Phone/Fax

Practice location:
  • Phone: 817-272-2011
  • Fax: 817-272-5006
Mailing address:
  • Phone: 817-272-2011
  • Fax: 817-272-5006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: