Provider Demographics
NPI:1598591935
Name:WAGNER, JANE ANNETTE
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:ANNETTE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 GREEN HOLLY CRES
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-6004
Mailing Address - Country:US
Mailing Address - Phone:757-818-0764
Mailing Address - Fax:
Practice Address - Street 1:2076 S INDEPENDENCE BLVD STE 1C
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23453-4773
Practice Address - Country:US
Practice Address - Phone:727-275-7622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VABACB1172214106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician