Provider Demographics
NPI:1194176784
Name:WAGNER, JACOB NORMAN
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:NORMAN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17293 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48240-2302
Mailing Address - Country:US
Mailing Address - Phone:313-948-7199
Mailing Address - Fax:
Practice Address - Street 1:17293 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48240-2302
Practice Address - Country:US
Practice Address - Phone:313-948-7199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-25
Last Update Date:2016-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other