Provider Demographics
NPI:1760880314
Name:WAGONER, JEANNE
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:WAGONER
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 1:17556 FAIRLAWN DR
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44023-6419
Mailing Address - Country:US
Mailing Address - Phone:216-320-3136
Mailing Address - Fax:
Practice Address - Street 1:2400 ROXBORO RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND HTS
Practice Address - State:OH
Practice Address - Zip Code:44106-3624
Practice Address - Country:US
Practice Address - Phone:216-320-3136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34778885174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist