| Doctor Name: | JASON ROBERT WAGNER |
| NPI Number: | 1053700765 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | ACMHC |
| License Number: | 7717626-6009 |
| Business Practice Address: | 8728 S 120 E Sandy, UT - 840701526 |
| Business Phone Number: | 8012432928 |
| Business Fax Number: | |
| Mailing Address: | 9880 S Countrywood Dr, SANDY |
| State: | UT |
| Postal Code: | 840923754 |
| Phone Number: | 8012432928 |
| Fax Number: | |
| NPI Enumeration Date: | 01/19/2015 |
| NPI Last Update Date: | 01/19/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | 7717626-6009 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | UT |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |