Provider Demographics
NPI:1437483245
Name:WAGNER, JANET
Entity Type:Individual
Prefix:MRS
First Name:JANET
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:PO BOX 412
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12748-0412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16 OLD COUNTY RD 128
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:NY
Practice Address - Zip Code:12748
Practice Address - Country:US
Practice Address - Phone:845-807-1132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-25
Last Update Date:2013-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006077-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant