Provider Demographics
NPI:1174582274
Name:WAGNER, JENNIFER RAE (MA, LAT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MA, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 S MONROE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:WI
Mailing Address - Zip Code:53813-2054
Mailing Address - Country:US
Mailing Address - Phone:608-723-3236
Mailing Address - Fax:608-723-3379
Practice Address - Street 1:507 S MONROE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:WI
Practice Address - Zip Code:53813-2054
Practice Address - Country:US
Practice Address - Phone:608-723-3236
Practice Address - Fax:608-723-3379
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer