Healthcare Provider Details

I. General information

NPI: 1396424842
Provider Name (Legal Business Name): JEFFREY WAGNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2023
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 NW 36TH ST STE 210
SEATTLE WA
98107-4959
US

IV. Provider business mailing address

100 N HOWARD ST STE W
SPOKANE WA
99201-0508
US

V. Phone/Fax

Practice location:
  • Phone: 425-640-7009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW70042194
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: