Provider Demographics
NPI:1972835759
Name:WAGGONER, JAMIE LYNN (RN, BSN)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2073 OLYMPIC ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-3413
Mailing Address - Country:US
Mailing Address - Phone:541-682-3550
Mailing Address - Fax:541-682-3551
Practice Address - Street 1:1680 CHAMBERS ST
Practice Address - Street 2:SUITE 103
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-3655
Practice Address - Country:US
Practice Address - Phone:541-682-3550
Practice Address - Fax:541-682-3551
Is Sole Proprietor?:No
Enumeration Date:2010-02-04
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OR201406916RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health