Jacqueline Lee Wagner, ARNP

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

NP1283A Issued in ID

Practice address

1713 E Sherman Ave
Coeur D Alene, ID 83814-5326

Phone

(208) 966-4087

Fax

(208) 966-4031

NPI assigned

Jan 28, 2013

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Jacqueline Lee Cruz-Aedo Former name

Medicare fee-for-service enrollment

Enrolled in ID

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Nurse Practitioner

Education

Other, 2012

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Practice addresses (Care Compare)

Hospital & facility affiliations

• Northwest Specialty Hospital Hospital, Post Falls, ID, CCN 130066

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Family Practice by the Lake LLC

  • Family Medicine Physician
  • Coeur D Alene, ID
  • NPI 1295283810
  Medicare reassignment Authorized official
• Kootenai Health, Inc.

  • Psychiatry Physician
  • Coeur D Alene, ID
  • NPI 1174661151
  NPD (past)
• Kootenai Health, Inc.

  • Emergency Medicine Physician
  • Coeur D Alene, ID
  • NPI 1235288655
  NPD (past)
• Centerwell Certified Healthcare Corp.

  • Home Health Agency
  • Spokane Valley, WA
  • NPI 1316294986

  Family Medicine

  NPD (past)

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• North Idaho Day Surgery LLC

  • Multi-Specialty Clinic/Center
  • St Maries, ID
  • NPI 1093674301

  Hospital

  Care Compare affiliation
• North Idaho Day Surgery LLC

  • General Acute Care Hospital
  • Post Falls, ID
  • NPI 1104824739
  Care Compare affiliation
• North Idaho Day Surgery LLC

  • Sleep Medicine (Psychiatry & Neurology) Physician
  • Post Falls, ID
  • NPI 1649123589

  Hospital

  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1359331200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1471392000000",
    "number": "1447598362",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1713 E SHERMAN AVE",
            "city": "COEUR D ALENE",
            "state": "ID",
            "postal_code": "838145326",
            "telephone_number": "208-966-4087",
            "fax_number": "208-966-4031"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1713 E SHERMAN AVE",
            "city": "COEUR D ALENE",
            "state": "ID",
            "postal_code": "838145326",
            "telephone_number": "208-966-4087",
            "fax_number": "208-966-4031"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "JACQUELINE",
        "middle_name": "LEE",
        "credential": "ARNP",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2013-01-28",
        "last_updated": "2016-08-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "ID",
            "license": "NP1283A",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "JACQUELINE",
            "last_name": "CRUZ-AEDO",
            "middle_name": "LEE",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Austin Voigt, M.D.
• Glen P. Volyn, MD
• Hannah Marie Vonwahlde, PHARMD
• Sarah B Vore, OT
• Aaron Eugene Wagner, M.D.
• Anne Bacon Wagstaff, LPC
• Brett Michael Waite, PA-C
• Kenneth John Wakefield, M.D.
• Jaki Waldvogel
• Walgreen Co

• Family Medicine Physician in Coeur D Alene, ID
• Providers in Coeur D Alene, ID by specialty
• Family Medicine Physician in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 17, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.