Provider Demographics
NPI:1538898663
Name:WAGNER, KRISTIN ANN JESSOP (PSYD)
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:ANN JESSOP
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2278 MOODY RD STE D
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-1933
Mailing Address - Country:US
Mailing Address - Phone:478-929-0294
Mailing Address - Fax:478-923-9770
Practice Address - Street 1:2278 MOODY RD STE D
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-1933
Practice Address - Country:US
Practice Address - Phone:478-929-0294
Practice Address - Fax:478-923-9770
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004600103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical