Provider Demographics
NPI:1205428133
Name:WAGNER, JAZMINE (COTA)
Entity type:Individual
Prefix:
First Name:JAZMINE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9029 NW 83RD ST
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-9649
Mailing Address - Country:US
Mailing Address - Phone:405-612-7471
Mailing Address - Fax:
Practice Address - Street 1:9029 NW 83RD ST
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-9649
Practice Address - Country:US
Practice Address - Phone:405-612-7471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1858224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant