Provider Demographics
NPI:1417003559
Name:WAGNER, JESSICA LEIGH
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LEIGH
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEIGH
Other - Last Name:SCHAER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4300 78TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-4426
Mailing Address - Country:US
Mailing Address - Phone:727-560-1061
Mailing Address - Fax:
Practice Address - Street 1:500 7TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-2316
Practice Address - Country:US
Practice Address - Phone:727-767-6843
Practice Address - Fax:727-767-4715
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker