Provider Demographics
NPI:1871890681
Name:WAGNER, JENNIFER C (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:WAGNER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3127 BROADWAY E
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-3850
Mailing Address - Country:US
Mailing Address - Phone:206-325-3287
Mailing Address - Fax:
Practice Address - Street 1:2205 N 45TH ST
Practice Address - Street 2:UNIT A
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-6903
Practice Address - Country:US
Practice Address - Phone:206-547-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist