Provider Demographics
NPI:1679144836
Name:WAGNER, JONATHAN STEWART (LPC-MHSP, NCC)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:STEWART
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LPC-MHSP, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2141 W MOOSE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-5185
Mailing Address - Country:US
Mailing Address - Phone:615-426-7352
Mailing Address - Fax:
Practice Address - Street 1:2141 W MOOSE CREEK DR
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5185
Practice Address - Country:US
Practice Address - Phone:615-426-7352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4117101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNNAOtherNA