Provider Demographics
NPI:1003272253
Name:WAGNER, JAMIE DEE
Entity Type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:DEE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:DEE
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:89 WESTGAY DR APT B
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44313-7364
Mailing Address - Country:US
Mailing Address - Phone:330-347-3287
Mailing Address - Fax:
Practice Address - Street 1:89 WESTGAY DR APT B
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44313-7364
Practice Address - Country:US
Practice Address - Phone:330-347-3287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.021987174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist