Provider Demographics
NPI:1760769533
Name:WAGNER, JESSICA LYNN (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:LYNN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:DORPFELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1880 LANCASTER ST. ZOLLER SCHOOL
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12308
Mailing Address - Country:US
Mailing Address - Phone:518-370-8290
Mailing Address - Fax:518-881-3882
Practice Address - Street 1:1880 LANCASTER ST. ZOLLER SCHOOL
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308
Practice Address - Country:US
Practice Address - Phone:518-370-8290
Practice Address - Fax:518-881-3882
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012191-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03669165Medicaid