Provider Demographics
NPI:1124543657
Name:WAGNER, JESSICA ANN (RPH, PHARMD, BCPS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RPH, PHARMD, BCPS
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ANN
Other - Last Name:LOUTHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH, PHARMD, BCPS
Mailing Address - Street 1:1501 SAN PEDRO DR SE # 119
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-5153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1310 24TH AVE S
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37212-2637
Practice Address - Country:US
Practice Address - Phone:615-327-4751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-05
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26027064A1835C0205X, 1835X0200X, 183500000X, 1835G0303X, 1835N1003X, 1835P0018X, 1835P1300X, 1835P2201X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835C0205XPharmacy Service ProvidersPharmacistCritical Care
No1835X0200XPharmacy Service ProvidersPharmacistOncology
No1835G0303XPharmacy Service ProvidersPharmacistGeriatric
No1835N1003XPharmacy Service ProvidersPharmacistNutrition Support
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No1835P1300XPharmacy Service ProvidersPharmacistPsychiatric
No1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy