Provider Demographics
NPI:1003677246
Name:WAGNER, JILL FRANCENE (PT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:FRANCENE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27818 NE 141ST ST
Mailing Address - Street 2:
Mailing Address - City:DUVALL
Mailing Address - State:WA
Mailing Address - Zip Code:98019-6307
Mailing Address - Country:US
Mailing Address - Phone:206-650-5675
Mailing Address - Fax:
Practice Address - Street 1:12040 NE 128TH ST # MS -103
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3013
Practice Address - Country:US
Practice Address - Phone:425-531-4615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00004042225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist