Provider Demographics
NPI:1679879050
Name:WAGNON, JEREMY M (DC)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:M
Last Name:WAGNON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-4642
Mailing Address - Country:US
Mailing Address - Phone:404-754-6779
Mailing Address - Fax:
Practice Address - Street 1:615 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-4642
Practice Address - Country:US
Practice Address - Phone:404-754-6779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-02
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008777111N00000X
WI4838-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor