Provider Demographics
NPI:1497590277
Name:WAGNER, JACOB ARNOLD (LSP, EDS)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:ARNOLD
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LSP, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2292 CHAMBLISS AVE NW STE C2
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-3862
Mailing Address - Country:US
Mailing Address - Phone:423-479-5672
Mailing Address - Fax:423-479-5679
Practice Address - Street 1:2292 CHAMBLISS AVE NW STE C2
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-3862
Practice Address - Country:US
Practice Address - Phone:423-479-5672
Practice Address - Fax:423-479-5679
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YS0200X
TN000748846103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool