Provider Demographics
NPI:1396176129
Name:WAGENKNECHT, JOHN JR (LCSW)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:WAGENKNECHT
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6981 TIMBER RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-8909
Mailing Address - Country:US
Mailing Address - Phone:715-577-7130
Mailing Address - Fax:
Practice Address - Street 1:2925 MONDOVI RD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6141
Practice Address - Country:US
Practice Address - Phone:715-832-0238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-04
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7214-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical