Provider Demographics
NPI:1952709693
Name:WAGONER, JAY FREDERICK (DC)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:FREDERICK
Last Name:WAGONER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 ROLLING RIDGE DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-7696
Mailing Address - Country:US
Mailing Address - Phone:814-954-4182
Mailing Address - Fax:
Practice Address - Street 1:454 ROLLING RIDGE DR
Practice Address - Street 2:SUITE 4
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-7696
Practice Address - Country:US
Practice Address - Phone:814-954-4182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC010942111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor