Provider Demographics
NPI:1952842346
Name:WAGNER, JAMES EVERETT (BS, QMHA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:EVERETT
Last Name:WAGNER
Suffix:
Gender:M
Credentials:BS, QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 SW RAMSEY AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5500
Mailing Address - Country:US
Mailing Address - Phone:541-474-5579
Mailing Address - Fax:
Practice Address - Street 1:1175 E MAIN ST STE 1C
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7457
Practice Address - Country:US
Practice Address - Phone:541-772-0127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-17
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1952842346Medicaid