Provider Demographics
NPI:1801114012
Name:WAGNER, JEAN (ND)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 HEMINGWAY RD
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-2629
Mailing Address - Country:US
Mailing Address - Phone:248-881-6220
Mailing Address - Fax:
Practice Address - Street 1:425 S MAIN ST
Practice Address - Street 2:STE. 201
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-6729
Practice Address - Country:US
Practice Address - Phone:248-881-6220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath