Jerome Peter Wagner, PH.D.

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

Practice address

2603 Broadway Ave
Evanston, IL 60201-1501

Phone

(847) 492-1690

NPI assigned

Aug 9, 2006

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in IL

Eligible to order & refer

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

Green means eligible to order or refer.

Enrollment records 1

Specialty

Clinical Psychologist

Education

Loyola University of Chicago, Stritch School of Medicine, 1981

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Philosophy

State licenses

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

{
    "created_epoch": "1155081600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1487664850",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2603 BROADWAY AVE",
            "city": "EVANSTON",
            "state": "IL",
            "postal_code": "602011501"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2603 BROADWAY AVE",
            "city": "EVANSTON",
            "state": "IL",
            "postal_code": "602011501",
            "telephone_number": "847-492-1690"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "JEROME",
        "middle_name": "PETER",
        "name_prefix": "Dr.",
        "credential": "PH.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-08-09",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "IL",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Christian Wacker
• Elizabeth Wade
• Kanika Wadhwa, LCPC
• Rahul Wadke, M.D.
• Arnold L Wagner Jr., M.D.
• Suleimaan Waheed, DO
• Michael S. Wahl, MD
• Dyson Wake, PHARM.D.
• Wakeful Psychological and Consulting Services, PLLC
• Gwenn Waldman, L.C.P.C.

• Clinical Psychologist in Evanston, IL
• Providers in Evanston, IL by specialty
• Clinical Psychologist in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; 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.