Individual
MR. JONATHAN STEWART WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LPC-MHSP, NCC
Contact information
Practice address
2141 W MOOSE CREEK DR, NAMPA, ID 83686-5185
(615) 426-7352
Mailing address
2141 W MOOSE CREEK DR, NAMPA, ID 83686-5185
(615) 426-7352
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
4117
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
NA
NA
TN
Enumeration date
07/08/2021
Last updated
07/08/2021
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