Provider Demographics
NPI:1730629361
Name:WAGNER, JEAN MARIE (LMFT)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:MARIE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16569 INTERLACHEN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-4601
Mailing Address - Country:US
Mailing Address - Phone:612-414-9544
Mailing Address - Fax:
Practice Address - Street 1:7580 160TH ST W
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-8348
Practice Address - Country:US
Practice Address - Phone:952-564-6276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3028106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist