Provider Demographics
NPI:1578798914
Name:WAGNER, JEFFREY MARK (PT, CHT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MARK
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PT, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 ESPLANADE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-3366
Mailing Address - Country:US
Mailing Address - Phone:530-894-0221
Mailing Address - Fax:530-894-0285
Practice Address - Street 1:1430 ESPLANADE
Practice Address - Street 2:SUITE 8
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-3366
Practice Address - Country:US
Practice Address - Phone:530-894-0221
Practice Address - Fax:530-894-0285
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-28
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT17374225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist