Provider Demographics
NPI:1235254459
Name:WAGNAAR, JEFFREY LYNN (PT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LYNN
Last Name:WAGNAAR
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 KING ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80219-1326
Mailing Address - Country:US
Mailing Address - Phone:303-225-4100
Mailing Address - Fax:303-486-5501
Practice Address - Street 1:325 KING ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80219-1326
Practice Address - Country:US
Practice Address - Phone:303-225-4100
Practice Address - Fax:303-486-5501
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL-6924225100000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist