MEDICARE: JANISSA J WAGNER

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
1	106E00000X	Assistant Behavior Analyst

General Provider Information

NPI Number	:	1245025725
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANISSA J WAGNER

Provider Business Mailing Address
First Line	:	17575 STATE ROUTE M
Second Line	:
City	:	EDGAR SPRINGS
State	:	MO
Zip	:	65462-8303
Country	:	US
Telephone Number	:	573-578-3830
Fax Number	:

Provider Business Practice Location Address
First Line	:	17575 STATE ROUTE M
Second Line	:
City	:	EDGAR SPRINGS
State	:	MO
Zip	:	65462-8303
Country	:	US
Telephone Number	:	573-578-3830
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2025
Last Update Date	:	04/14/2025

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Directions to “ JANISSA J WAGNER ” Practice Location

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