Provider Demographics
NPI:1528243375
Name:WAGNER, JENNIFER (LMHC, SUDPT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LMHC, SUDPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:KLEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC, SUDPT
Mailing Address - Street 1:232 2ND AVE S STE 201
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-5862
Mailing Address - Country:US
Mailing Address - Phone:253-859-0300
Mailing Address - Fax:253-859-3017
Practice Address - Street 1:232 2ND AVE S STE 201
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-5862
Practice Address - Country:US
Practice Address - Phone:253-859-0300
Practice Address - Fax:253-859-0745
Is Sole Proprietor?:No
Enumeration Date:2007-12-28
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60662255101YA0400X
101YM0800X
WACO60662255390200000X
WALH 60242120101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program