Individual
JAMIE R WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LCPC, LPC, RPT-S
Contact information
Practice address
11447 2ND ST, SUITE 9B, ROSCOE, IL 61073-9522
(815) 601-4673
(866) 303-8062
Mailing address
3705 TANGLEWOOD PL, JANESVILLE, WI 53546-7800
(608) 290-6705
(866) 303-8062
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
3206-125
WI
101YP2500X
Professional Counselor
Primary
180033993
IL
101YP2500X
Professional Counselor
3206-125
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
14270
DEAN INSURANCE
WI
01
—
180033993
LICENCED CLIN. PROF. COUN
IL
01
—
3206-125
LPC
WI
05
—
41000700
—
WI
Enumeration date
06/16/2006
Last updated
11/22/2023
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