Provider Demographics
NPI:1538653118
Name:WAGNER, JENNIFER (LISW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1039 CHARLETON DR
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-4335
Mailing Address - Country:US
Mailing Address - Phone:330-413-6493
Mailing Address - Fax:
Practice Address - Street 1:619 TREMONT AVE SW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44647-6468
Practice Address - Country:US
Practice Address - Phone:330-837-3555
Practice Address - Fax:330-837-0513
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0028718104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker