Provider Demographics
NPI:1497006332
Name:WAGSTER, JODI JEAN (LMP)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:JEAN
Last Name:WAGSTER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5631 123RD AVE SE
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98290-5510
Mailing Address - Country:US
Mailing Address - Phone:206-605-3890
Mailing Address - Fax:
Practice Address - Street 1:2804 GRAND AVE STE 300
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3586
Practice Address - Country:US
Practice Address - Phone:206-605-3890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60297122174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist