Provider Demographics
NPI:1760939136
Name:WAGNER, JORDAN ANN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ANN
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 1:3351 FALLSTON RD
Mailing Address - Street 2:
Mailing Address - City:FALLSTON
Mailing Address - State:MD
Mailing Address - Zip Code:21047-1020
Mailing Address - Country:US
Mailing Address - Phone:443-299-8208
Mailing Address - Fax:
Practice Address - Street 1:3351 FALLSTON RD
Practice Address - Street 2:
Practice Address - City:FALLSTON
Practice Address - State:MD
Practice Address - Zip Code:21047-1020
Practice Address - Country:US
Practice Address - Phone:443-299-8208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-02
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer