Provider Demographics
NPI:1346995008
Name:WAGNER, JERRY MAIN
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:MAIN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1494 CAMP CREEK RD
Mailing Address - Street 2:
Mailing Address - City:UNION MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28167-7900
Mailing Address - Country:US
Mailing Address - Phone:828-423-6024
Mailing Address - Fax:
Practice Address - Street 1:1494 CAMP CREEK RD
Practice Address - Street 2:
Practice Address - City:UNION MILLS
Practice Address - State:NC
Practice Address - Zip Code:28167-7900
Practice Address - Country:US
Practice Address - Phone:828-423-6886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0186301041C0700X
P0186791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical