| Doctor Name: | DR. JACK LAURENCE WAPNER |
| NPI Number: | 1164688677 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.D. |
| License Number: | D0026048 |
| Business Practice Address: | 11100 Liberty Rd Suite F Randallstown, MD - 211331026 |
| Business Phone Number: | 4106552740 |
| Business Fax Number: | 4106554740 |
| Mailing Address: | 11100 Liberty Rd, Suite F RANDALLSTOWN |
| State: | MD |
| Postal Code: | 211331026 |
| Phone Number: | 4106552740 |
| Fax Number: | 4106554740 |
| NPI Enumeration Date: | 08/04/2008 |
| NPI Last Update Date: | 08/04/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 2084A0401X |
| License Number: | D0026048 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MD |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | Psychiatry & Neurology |
| Taxonomy Specialization: | Addiction Medicine |
| Taxonomy Definition: | A doctor of osteopathy board eligible/certified in the field of Psychiatry by the American Osteopathic Board of Neurology and Psychiatry is able to obtain a Certificate of Added Qualifications in the field of Addiction Medicine |