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General NPI Number Information
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NPI Number | 1295947778
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Entity Type | Individual
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Provider Name | JODI LYNN WAGNER OTR
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Gender | Female
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Dates
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Enumeration Date | 05/04/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2629 NORTH 7TH STREET
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City | SHEBOYGAN
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State | WI
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Zip | 53083
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Country | US
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Telephone | 920-451-5000
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Fax |
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Provider Business Mailing Address
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Address Line | 20 SOUTH STREET
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City | PLYMOUTH
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State | WI
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Zip | 53073-2420
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Country | US
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Telephone | 920-893-8222
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 3368-026
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License Number State | WI
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