Provider Demographics
NPI:1518298058
Name:WAGNER, JESSICA (PT)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:MILOSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-7401
Mailing Address - Country:US
Mailing Address - Phone:815-206-3388
Mailing Address - Fax:815-337-2763
Practice Address - Street 1:2000 LAKE AVE
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-7401
Practice Address - Country:US
Practice Address - Phone:815-206-3388
Practice Address - Fax:815-337-2763
Is Sole Proprietor?:No
Enumeration Date:2010-01-22
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070011316225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist