Provider Demographics
NPI:1134707045
Name:BAGBY, JACKSON PHILIP (DO)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:PHILIP
Last Name:BAGBY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 CAHILL RD STE 206
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-1911
Mailing Address - Country:US
Mailing Address - Phone:417-348-8100
Mailing Address - Fax:
Practice Address - Street 1:121 CAHILL RD STE 206
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-1911
Practice Address - Country:US
Practice Address - Phone:417-348-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020235730207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine