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General NPI Number Information
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NPI Number | 1881509610
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Entity Type | Individual
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Provider Name | JACKSON TYLER WAGENER
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Gender | Male
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Dates
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Enumeration Date | 08/17/2026
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Last Update Date | 08/17/2026
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Provider Practice Location Address
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Address Line | 813 BRYDEN RD
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City | COLUMBUS
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State | OH
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Zip | 43205-1759
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Country | US
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Telephone | 614-808-3198
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Fax |
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Provider Business Mailing Address
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Address Line | 198 E NORWICH AVE
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City | COLUMBUS
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State | OH
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Zip | 43201-1200
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Country | US
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Telephone | 419-410-0895
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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 | APP-001105546
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License Number State | OH
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