Provider Demographics
NPI:1427445279
Name:WAGNER, JENNIFER (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:648 HARTSVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-2523
Mailing Address - Country:US
Mailing Address - Phone:615-451-9246
Mailing Address - Fax:615-452-7862
Practice Address - Street 1:648 HARTSVILLE PIKE
Practice Address - Street 2:
Practice Address - City:GALLATIN
Practice Address - State:TN
Practice Address - Zip Code:37066
Practice Address - Country:US
Practice Address - Phone:615-451-9246
Practice Address - Fax:615-452-7862
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN57147208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program