Provider Demographics
NPI:1013352194
Name:WAGGONER, JOHN ROBERT JR (BA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:WAGGONER
Suffix:JR
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 ELM ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-5122
Mailing Address - Country:US
Mailing Address - Phone:720-202-7387
Mailing Address - Fax:
Practice Address - Street 1:4455 E 12TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-2415
Practice Address - Country:US
Practice Address - Phone:303-504-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-03
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health