Individual
JASON FREDRICK WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
APRN, LMHC, MCAP
Contact information
Practice address
111 W CORAL WAY, HOLLYWOOD, FL 33021-3860
(954) 964-6338
(954) 965-1327
Mailing address
135 WESTON RD # 236, WESTON, FL 33326-1111
(954) 483-5455
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
MH8961
FL
101YM0800X
Mental Health Counselor
MH8961
FL
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
APRN11004343
FL
Other
Enumeration date
09/20/2016
Last updated
05/01/2024
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