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General NPI Number Information
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NPI Number | 1427618289
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Entity Type | Individual
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Provider Name | JENNIFER RENEE WAGGONER
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Gender | Female
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Dates
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Enumeration Date | 06/14/2019
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Last Update Date | 06/20/2019
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Provider Practice Location Address
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Address Line | 427 W ORCHARD ST STE D
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City | VANDALIA
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State | IL
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Zip | 62471-1256
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Country | US
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Telephone | 618-322-4491
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Fax |
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Provider Business Mailing Address
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Address Line | 6700 WASHINGTON AVE S
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City | EDEN PRAIRIE
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State | MN
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Zip | 55344-3405
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Country | US
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Telephone | 460-295-2947
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Fax | 163-750-7512
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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 | 237600000X
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Taxonomy Name | Audiologist-Hearing Aid Fitter
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 237700000X
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Taxonomy Name | Hearing Instrument Specialist
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License Number | 3360
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License Number State | IL
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