Provider Demographics
NPI:1558701839
Name:WAGNER, JESSICA LEIGH (MED, BS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MED, BS
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEIGH
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, BS
Mailing Address - Street 1:901 N MONROE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-2104
Mailing Address - Country:US
Mailing Address - Phone:509-328-2740
Mailing Address - Fax:509-328-0773
Practice Address - Street 1:901 N MONROE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2104
Practice Address - Country:US
Practice Address - Phone:509-328-2740
Practice Address - Fax:509-328-0773
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60389811103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst