MEDICARE: JANE ANNETTE 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	106S00000X	Behavior Technician	BACB1172214	VA

General Provider Information

NPI Number	:	1598591935
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANE ANNETTE WAGNER

Provider Business Mailing Address
First Line	:	3400 GREEN HOLLY CRES
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-6004
Country	:	US
Telephone Number	:	757-818-0764
Fax Number	:

Provider Business Practice Location Address
First Line	:	2076 S INDEPENDENCE BLVD STE 1C
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23453-4773
Country	:	US
Telephone Number	:	727-275-7622
Fax Number	:

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

Provider Enumeration Date	:	09/11/2024
Last Update Date	:	09/11/2024

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