Provider Demographics
NPI:1659745073
Name:WAGNER, JACKLYN MARIE (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:MARIE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:JACKLYN
Other - Middle Name:MARIE
Other - Last Name:BOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT, ATC
Mailing Address - Street 1:7100 ANDALUCIA ST
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-5950
Mailing Address - Country:US
Mailing Address - Phone:585-880-3209
Mailing Address - Fax:
Practice Address - Street 1:36000 DARNALL LOOP
Practice Address - Street 2:CARL R. DARNALL ARMY MEDICAL CENTER
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5095
Practice Address - Country:US
Practice Address - Phone:254-286-7326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-23
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT5423225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist