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NPI Code Detail

MEDICARE: JACQUELYN WAGNER MS CCC-SLP

MEDICARE: JACQUELYN WAGNER MS CCC-SLP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1235Z00000XSpeech-Language Pathologist242.000217IL
2235Z00000XSpeech-Language Pathologist2978154WI

General Provider Information

NPI Number : 1134290935
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACQUELYN WAGNER MS CCC-SLP
Provider Business Mailing Address
First Line : 833 N 26TH STREET
Second Line :
City : MILWAUKEE
State : WI
Zip : 53233-4345
Country : US
Telephone Number : 414-344-7676
Fax Number :
Provider Business Practice Location Address
First Line : 833 N 26TH ST
Second Line :
City : MILWAUKEE
State : WI
Zip : 53233-1507
Country : US
Telephone Number : 414-344-7676
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/13/2006
Last Update Date : 09/18/2008

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Directions to “ JACQUELYN WAGNER MS CCC-SLP” Practice Location

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