Provider Demographics
NPI:1255906145
Name:WAGNER, JORDAN ELAINE (LGMFT)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:ELAINE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LGMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11232 ANGLEBERGER RD
Mailing Address - Street 2:
Mailing Address - City:THURMONT
Mailing Address - State:MD
Mailing Address - Zip Code:21788-2503
Mailing Address - Country:US
Mailing Address - Phone:443-605-7203
Mailing Address - Fax:
Practice Address - Street 1:2126 CAISSON RD
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-6806
Practice Address - Country:US
Practice Address - Phone:301-473-2197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGM810106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist