Provider Demographics
NPI:1326935800
Name:WAGNER, JORDAN (LM, CPM)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3414 TRUMPETER DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-8607
Mailing Address - Country:US
Mailing Address - Phone:530-736-0250
Mailing Address - Fax:
Practice Address - Street 1:916 S 3RD ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-4324
Practice Address - Country:US
Practice Address - Phone:530-736-0250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-18
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMIDW.MW.61663618176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife