Provider Demographics
NPI:1326487679
Name:WAGNER, JEAN L (LPCC)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 S. BEECH ST.
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506
Mailing Address - Country:US
Mailing Address - Phone:419-633-3333
Mailing Address - Fax:419-754-2255
Practice Address - Street 1:113 S. BEECH ST.
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506
Practice Address - Country:US
Practice Address - Phone:419-633-3333
Practice Address - Fax:419-754-2255
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0025485104100000X
OHE.1200270101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker