Provider Demographics
NPI:1821427287
Name:WAGNER, JASON LEIGH (LMHC)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:LEIGH
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 5TH ST.
Mailing Address - Street 2:SUITE 520
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51101
Mailing Address - Country:US
Mailing Address - Phone:712-259-2681
Mailing Address - Fax:
Practice Address - Street 1:505 5TH ST.
Practice Address - Street 2:SUITE 520
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101
Practice Address - Country:US
Practice Address - Phone:712-259-2681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001550101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health