Provider Demographics
NPI:1679042154
Name:WAGNER, JENNIFER A (RN00154307)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RN00154307
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4304 W CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3257
Mailing Address - Country:US
Mailing Address - Phone:509-823-4200
Mailing Address - Fax:509-823-4220
Practice Address - Street 1:4304 W CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3257
Practice Address - Country:US
Practice Address - Phone:509-823-4200
Practice Address - Fax:509-823-4220
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00154307163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse