Provider Demographics
NPI:1982184503
Name:WAGNER, JILLIAN (RDN, LDN)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 AVENUE A
Mailing Address - Street 2:
Mailing Address - City:SCHUYLKILL HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17972-1302
Mailing Address - Country:US
Mailing Address - Phone:570-225-1848
Mailing Address - Fax:
Practice Address - Street 1:300 MOUNT LEBANON BLVD STE 209C
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15234-1507
Practice Address - Country:US
Practice Address - Phone:412-720-3343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN006463133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered