Provider Demographics
NPI:1710697099
Name:JENNIFER WAGNER, MA, CCC-SLP: PEDIATRIC SPEECH AND LANGUAGE SERVICES
Entity Type:Organization
Organization Name:JENNIFER WAGNER, MA, CCC-SLP: PEDIATRIC SPEECH AND LANGUAGE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:206-227-7199
Mailing Address - Street 1:3417 EVANSTON AVE N STE 311
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-8967
Mailing Address - Country:US
Mailing Address - Phone:206-227-7199
Mailing Address - Fax:
Practice Address - Street 1:3417 EVANSTON AVE N STE 311
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-8967
Practice Address - Country:US
Practice Address - Phone:206-227-7199
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty