Active NPI
Feyissa Jafar Wagesso
- Assisted Living Facility
- Maplewood, MN
National Provider Identifier
1699511253
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Assisted Living Facility
- Practice address
- 2468 Brenner Ave E
Maplewood, MN 55109-1573 - Phone
- (763) 910-7300
- Fax
- (218) 979-7692
- NPI assigned
- Jul 3, 2024
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Assisted Living Facility (Behavioral Disturbances) | 3104A0630X | |||
| Assisted Living Facility | 310400000X | Primary |
Addresses
Primary practice location
2468 Brenner Ave E
Maplewood, MN 55109-1573
Mailing address
2468 Brenner Ave E
Maplewood, MN 55109-1573
Phone (763) 910-7300
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| A636435500 | Medicaid | MN |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1719964800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1754611200000",
"number": "1699511253",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2468 BRENNER AVE E",
"city": "MAPLEWOOD",
"state": "MN",
"postal_code": "551091573",
"telephone_number": "763-910-7300",
"fax_number": "218-979-7692"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2468 BRENNER AVE E",
"city": "MAPLEWOOD",
"state": "MN",
"postal_code": "551091573",
"telephone_number": "763-910-7300",
"fax_number": "218-979-7692"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGESSO",
"first_name": "FEYISSA",
"middle_name": "JAFAR",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2024-07-03",
"last_updated": "2025-08-08",
"certification_date": "2025-08-08",
"status": "A"
},
"taxonomies": [
{
"code": "3104A0630X",
"taxonomy_group": "",
"desc": "Assisted Living Facility, Assisted Living, Behavioral Disturbances",
"state": null,
"license": null,
"primary": false
},
{
"code": "310400000X",
"taxonomy_group": "",
"desc": "Assisted Living Facility",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "A636435500",
"state": "MN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Maplewood, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 8, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.