1497590277 NPI number — MR. JACOB ARNOLD WAGNER LSP, ED.S

Table of content: MR. JACOB ARNOLD WAGNER LSP, ED.S (NPI 1497590277)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497590277 NPI number — MR. JACOB ARNOLD WAGNER LSP, ED.S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGNER
Provider First Name:
JACOB
Provider Middle Name:
ARNOLD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LSP, ED.S
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497590277
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2292 CHAMBLISS AVE NW STE C2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37311-3862
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-479-5672
Provider Business Mailing Address Fax Number:
423-479-5679

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2292 CHAMBLISS AVE NW STE C2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37311-3862
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-479-5672
Provider Business Practice Location Address Fax Number:
423-479-5679
Provider Enumeration Date:
06/25/2024

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: 101YS0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TS0200X , with the licence number: 000748846 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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