Provider Demographics
NPI:1144408949
Name:WAGNER-GARNER, JANE ELLEN (MA)
Entity Type:Individual
Prefix:MRS
First Name:JANE
Middle Name:ELLEN
Last Name:WAGNER-GARNER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 WEST PINE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1614
Mailing Address - Country:US
Mailing Address - Phone:573-701-5902
Mailing Address - Fax:
Practice Address - Street 1:118 W PINE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1403
Practice Address - Country:US
Practice Address - Phone:573-701-5902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-04
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002053101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional