Provider Demographics
NPI:1518290360
Name:WAGNER, JILL KAREN (PT)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:KAREN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 W BROAD ST
Mailing Address - Street 2:SUITE 214-A
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-3340
Mailing Address - Country:US
Mailing Address - Phone:703-606-6213
Mailing Address - Fax:703-620-0843
Practice Address - Street 1:450 W BROAD ST
Practice Address - Street 2:SUITE 214-A
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-3340
Practice Address - Country:US
Practice Address - Phone:703-606-6213
Practice Address - Fax:703-620-0843
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-11
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01050051062251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics