Provider Demographics
NPI:1073557229
Name:WAGNER, JAMIE R (LCPC, LPC, RPT-S)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:R
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LCPC, LPC, RPT-S
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:R
Other - Last Name:REDDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC, LPC, RPT-S
Mailing Address - Street 1:3705 TANGLEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-7800
Mailing Address - Country:US
Mailing Address - Phone:608-290-6705
Mailing Address - Fax:866-303-8062
Practice Address - Street 1:11447 2ND ST
Practice Address - Street 2:SUITE 9B
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-9522
Practice Address - Country:US
Practice Address - Phone:815-601-4673
Practice Address - Fax:866-303-8062
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3206-125101YM0800X, 101YP2500X
IL180033993101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI14270OtherDEAN INSURANCE
IL180033993OtherLICENCED CLIN. PROF. COUN
WI3206-125OtherLPC
WI41000700Medicaid