| Doctor Name: | JAMIE R WAGNER |
| NPI Number: | 1073557229 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LCPC, LPC, RPT |
| License Number: | 180033993 |
| Business Practice Address: | 11447 2nd St Suite 9b Roscoe, IL - 610739522 |
| Business Phone Number: | 8156014673 |
| Business Fax Number: | 8663038062 |
| Mailing Address: | 1748 Gateway Blvd, BELOIT |
| State: | WI |
| Postal Code: | 535119801 |
| Phone Number: | 6082906705 |
| Fax Number: | 8663038062 |
| NPI Enumeration Date: | 06/16/2006 |
| NPI Last Update Date: | 09/14/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YP2500X |
| License Number: | 180033993 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | IL |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Professional |
| Taxonomy Definition: | |