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General NPI Number Information
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NPI Number | 1427445279
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Entity Type | Individual
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Provider Name | JENNIFER WAGNER M.D.
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Gender | Female
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Dates
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Enumeration Date | 04/20/2015
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Last Update Date | 01/08/2026
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Provider Practice Location Address
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Address Line | 534 NAUTICAL DR STE 2
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City | CLOVER
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State | SC
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Zip | 29710-8182
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Country | US
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Telephone | 803-619-4121
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Fax | 803-965-3119
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Provider Business Mailing Address
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Address Line | 534 NAUTICAL DR STE 2
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City | CLOVER
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State | SC
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Zip | 29710-8182
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Country | US
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Telephone | 803-619-4121
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Fax | 803-965-3119
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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 | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 2026-00005
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 96214
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License Number State | SC
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Taxonomy #3
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 57147
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License Number State | TN
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