Provider Demographics
NPI:1902078983
Name:WAGNER, JEANNIE CHIEN (PT)
Entity Type:Individual
Prefix:MS
First Name:JEANNIE
Middle Name:CHIEN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 W BARAGA AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4068
Mailing Address - Country:US
Mailing Address - Phone:906-226-0143
Mailing Address - Fax:906-226-0152
Practice Address - Street 1:1055 W BARAGA AVE
Practice Address - Street 2:SUITE D
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4068
Practice Address - Country:US
Practice Address - Phone:906-226-0143
Practice Address - Fax:906-226-0152
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-30
Last Update Date:2008-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004592225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist