Provider Demographics
NPI:1285384750
Name:WAGNER, DEBORAH JESSICA (LCSW)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:JESSICA
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 CHILDRENS WAY # MC5100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4223
Mailing Address - Country:US
Mailing Address - Phone:858-576-1700
Mailing Address - Fax:
Practice Address - Street 1:4305 UNIVERSITY AVE STE 150
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1690
Practice Address - Country:US
Practice Address - Phone:858-576-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-26
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC50078648104100000X
CALCSW1091851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker