Provider Demographics
NPI:1679767396
Name:WAGNER, JENNIFER L (AUD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:HILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2035 COMMERCE DR STE 208
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:IN
Mailing Address - Zip Code:46714-9295
Mailing Address - Country:US
Mailing Address - Phone:260-706-2558
Mailing Address - Fax:
Practice Address - Street 1:2035 COMMERCE DR STE 208
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:IN
Practice Address - Zip Code:46714-9295
Practice Address - Country:US
Practice Address - Phone:260-706-2558
Practice Address - Fax:260-435-1595
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-06
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002421A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200874560Medicaid
IN047930WMedicare PIN