Provider Demographics
NPI:1063466431
Name:WAGNER, JESSICA (OD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 W FRONT ST
Mailing Address - Street 2:#146
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4164 E BLUEGRASS RD
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858
Practice Address - Country:US
Practice Address - Phone:989-772-9481
Practice Address - Fax:989-772-5431
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJW004356152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0B87610015Medicare ID - Type Unspecified