Provider Demographics
NPI:1710755103
Name:WAGNER, JEANNETTE
Entity Type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 S UNION ST
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:OH
Mailing Address - Zip Code:45106-1517
Mailing Address - Country:US
Mailing Address - Phone:513-546-1402
Mailing Address - Fax:
Practice Address - Street 1:419 S UNION ST
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:OH
Practice Address - Zip Code:45106-1517
Practice Address - Country:US
Practice Address - Phone:513-546-1402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker