Provider Demographics
NPI:1740077528
Name:WAGAR, JEFFREY MARTIN
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MARTIN
Last Name:WAGAR
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13642 N FREESTYLE LN
Mailing Address - Street 2:
Mailing Address - City:KAMAS
Mailing Address - State:UT
Mailing Address - Zip Code:84036-1316
Mailing Address - Country:US
Mailing Address - Phone:323-422-9600
Mailing Address - Fax:
Practice Address - Street 1:175 N MAIN ST STE 204
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-1622
Practice Address - Country:US
Practice Address - Phone:435-709-3060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14218138-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health