Provider Demographics
NPI:1063259463
Name:WAGSTER, JAMIE L
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:L
Last Name:WAGSTER
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 1:1400 S OVERLAND DR
Mailing Address - Street 2:
Mailing Address - City:LENNON
Mailing Address - State:MI
Mailing Address - Zip Code:48449-9626
Mailing Address - Country:US
Mailing Address - Phone:989-413-8218
Mailing Address - Fax:
Practice Address - Street 1:11410 E LENNON RD
Practice Address - Street 2:
Practice Address - City:LENNON
Practice Address - State:MI
Practice Address - Zip Code:48449-9666
Practice Address - Country:US
Practice Address - Phone:810-621-4721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant