MEDICARE: JEFFREY MARTIN WAGAR

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	101YM0800X	Mental Health Counselor	14218138-6009	UT

General Provider Information

NPI Number	:	1740077528
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY MARTIN WAGAR

Provider Business Mailing Address
First Line	:	13642 N FREESTYLE LN
Second Line	:
City	:	KAMAS
State	:	UT
Zip	:	84036-1316
Country	:	US
Telephone Number	:	323-422-9600
Fax Number	:

Provider Business Practice Location Address
First Line	:	175 N MAIN ST STE 204
Second Line	:
City	:	HEBER CITY
State	:	UT
Zip	:	84032-1622
Country	:	US
Telephone Number	:	435-709-3060
Fax Number	:

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

Provider Enumeration Date	:	04/23/2025
Last Update Date	:	04/23/2025

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Directions to “ JEFFREY MARTIN WAGAR ” Practice Location

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