Provider Demographics
NPI:1033740980
Name:WAGNER GREGG, JESSICA LACHELLE (MSN, CRNP, CPNP-AC)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LACHELLE
Last Name:WAGNER GREGG
Suffix:
Gender:F
Credentials:MSN, CRNP, CPNP-AC
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:LACHELLE
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:6651 MAIN ST
Mailing Address - Street 2:STE E1420
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2432
Mailing Address - Country:US
Mailing Address - Phone:832-826-6240
Mailing Address - Fax:
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1590
Practice Address - Country:US
Practice Address - Phone:410-328-8667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-29
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC0029792080P0203X
MDR214732363LP0222X
TX1076101363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine