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General NPI Number Information
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NPI Number | 1720536691
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Entity Type | Individual
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Provider Name | JASON FREDRICK WAGNER APRN, LMHC, MCAP
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Gender | Male
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Dates
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Enumeration Date | 09/20/2016
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Last Update Date | 05/01/2024
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Provider Practice Location Address
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Address Line | 111 W CORAL WAY
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City | HOLLYWOOD
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State | FL
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Zip | 33021-3860
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Country | US
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Telephone | 954-964-6338
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Fax | 954-965-1327
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Provider Business Mailing Address
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Address Line | 135 WESTON RD # 236
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City | WESTON
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State | FL
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Zip | 33326-1111
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Country | US
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Telephone | 954-483-5455
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | MH8961
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH8961
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | APRN11004343
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License Number State | FL
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