1659745073 NPI number — JACKLYN MARIE WAGNER PT, DPT, ATC

Table of content: JACKLYN MARIE WAGNER PT, DPT, ATC (NPI 1659745073)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659745073 NPI number — JACKLYN MARIE WAGNER PT, DPT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGNER
Provider First Name:
JACKLYN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOSS
Provider Other First Name:
JACKLYN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT, ATC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659745073
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7100 ANDALUCIA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KILLEEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76542-5950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-880-3209
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36000 DARNALL LOOP
Provider Second Line Business Practice Location Address:
CARL R. DARNALL ARMY MEDICAL CENTER
Provider Business Practice Location Address City Name:
FORT HOOD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76544-5095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-286-7326
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/23/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT5423 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)