Provider Demographics
NPI:1871166066
Name:WAGNER, JENNIFER LEE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 S LAKE DR APT 4
Mailing Address - Street 2:
Mailing Address - City:ST FRANCIS
Mailing Address - State:WI
Mailing Address - Zip Code:53235-5256
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:800-863-5373
Practice Address - Street 1:8369 S 76TH ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-8520
Practice Address - Country:US
Practice Address - Phone:414-690-9437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002801-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist