Provider Demographics
NPI:1487656799
Name:WAGNER, JODY MICHELLE (DC)
Entity Type:Individual
Prefix:DR
First Name:JODY
Middle Name:MICHELLE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N110 BRUX RD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-9439
Mailing Address - Country:US
Mailing Address - Phone:920-968-0464
Mailing Address - Fax:
Practice Address - Street 1:N110 BRUX RD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-9439
Practice Address - Country:US
Practice Address - Phone:920-968-0464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4062-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38957300Medicaid
WIV02220Medicare UPIN
WI000175314Medicare ID - Type Unspecified