Jason Fredrick Wagner, APRN, LMHC, MCAP

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

License

APRN11004343 Issued in FL

Practice address

111 W Coral Way
Hollywood, FL 33021-3860

Phone

(954) 964-6338

Fax

(954) 965-1327

NPI assigned

Sep 20, 2016

Last updated

May 1, 2024By the provider in NPPES

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Enrolled in FL, TX2 enrollments

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 2

Specialty

Nurse Practitioner

Education

Other, 2019

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Seminole Tribe of FloridaGroup PAC ID 4082710835, 8 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Locations

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

• Seminole Tribe of Florida Health Dept.

  • Primary Care Clinic/Center
  • Hollywood, FL
  • NPI 1144551748

  TX

  Medicare reassignment Care Compare group NPD
• David Lawrence Mental Health Center, Inc

  • Community/Behavioral Health Agency
  • Naples, FL
  • NPI 1801891940
  Medicare reassignment NPD
• Seminole Tribe of Florida

  • Primary Care Clinic/Center
  • Clewiston, FL
  • NPI 1740551530
  NPD
• Seminole Tribe of Florida

  • Primary Care Clinic/Center
  • Immokalee, FL
  • NPI 1851662472
  NPD
• Medi MD

  • Substance Use Disorder Rehabilitation Clinic/Center
  • Davie, FL
  • NPI 1306094586
  NPD (past)

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

{
    "created_epoch": "1474329600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1714521600000",
    "number": "1720536691",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "135 WESTON RD # 236",
            "city": "WESTON",
            "state": "FL",
            "postal_code": "333261111",
            "telephone_number": "954-483-5455"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "111 W CORAL WAY",
            "city": "HOLLYWOOD",
            "state": "FL",
            "postal_code": "330213860",
            "telephone_number": "954-964-6338",
            "fax_number": "954-965-1327"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "JASON",
        "middle_name": "FREDRICK",
        "credential": "APRN, LMHC, MCAP",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2016-09-20",
        "last_updated": "2024-05-01",
        "certification_date": "2024-05-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "FL",
            "license": "APRN11004343",
            "primary": true
        },
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "FL",
            "license": "MH8961",
            "primary": false
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "FL",
            "license": "MH8961",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Michel Vulfovich, M.D.
• Trinh Le Vuong, PHARM.D.
• Dylan Ambrose Wadell, MD
• Abraham Wagner, DPM
• Edward Steven Wagner, MD
• William Wagner, M.D.
• Estrella N/a Wahnich
• Wal-Mart Stores East LP (Walmart Pharmacy 10-3163)
• Wal-Mart Stores East, LP (Walmart Vision Center 30-3163)
• Walgreen Co (Walgreens #7322)

• Psychiatric/Mental Health Nurse Practitioner in Hollywood, FL
• Providers in Hollywood, FL by specialty
• Psychiatric/Mental Health Nurse Practitioner in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 1, 2024; 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.