Provider Demographics
NPI:1366591356
Name:WAGNON, JEFFREY LYNN (DC)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LYNN
Last Name:WAGNON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 REGENCY PKWY STE 205
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-7305
Mailing Address - Country:US
Mailing Address - Phone:817-453-0430
Mailing Address - Fax:817-453-0400
Practice Address - Street 1:309 REGENCY PKWY STE 205
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-7305
Practice Address - Country:US
Practice Address - Phone:817-453-0430
Practice Address - Fax:817-453-0400
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9382111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8R1160OtherBLUE CROSS BLUE SHIELD #
TX8R1160OtherBLUE CROSS BLUE SHIELD #
TX259840YLCBMedicare PIN
TX8D4309Medicare ID - Type UnspecifiedMEDICARE ID NUMBER