Provider Demographics
NPI:1326307232
Name:WAGNER, JESSA
Entity Type:Individual
Prefix:
First Name:JESSA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3016 W CHARLESTON BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1973
Mailing Address - Country:US
Mailing Address - Phone:702-780-7118
Mailing Address - Fax:
Practice Address - Street 1:2655 ENTERPRISE RD
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89512-1666
Practice Address - Country:US
Practice Address - Phone:775-688-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-11
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
NVMI1250106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health Worker