Provider Demographics
NPI:1861646010
Name:WAGNER, JACQUELINE RAE (OTR/L)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RAE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 STONE CRK
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-9338
Mailing Address - Country:US
Mailing Address - Phone:715-441-1003
Mailing Address - Fax:
Practice Address - Street 1:1818 STONE CRK
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-9338
Practice Address - Country:US
Practice Address - Phone:715-441-1003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-13
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
MN103369225X00000X
WI6780-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist