MEDICARE: MRS. JENNIFER WAGNER LMHC, SUDPT

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	60662255	WA
2	101YM0800X	Mental Health Counselor
3	390200000X	Student in an Organized Health Care Education/Training Program	CO60662255	WA
4	101YM0800X	Mental Health Counselor	LH 60242120	WA

General Provider Information

NPI Number	:	1528243375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER WAGNER LMHC, SUDPT

Provider Business Mailing Address
First Line	:	232 2ND AVE S STE 201
Second Line	:
City	:	KENT
State	:	WA
Zip	:	98032-5862
Country	:	US
Telephone Number	:	253-859-0300
Fax Number	:	253-859-3017

Provider Business Practice Location Address
First Line	:	232 2ND AVE S STE 201
Second Line	:
City	:	KENT
State	:	WA
Zip	:	98032-5862
Country	:	US
Telephone Number	:	253-859-0300
Fax Number	:	253-859-0745

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

Provider Enumeration Date	:	12/28/2007
Last Update Date	:	03/16/2023

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