Provider Demographics
NPI:1871951061
Name:BAGLEY, JENNIFER ANDERSON (PT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANDERSON
Last Name:BAGLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:579 FAIRFIELD WAY
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3624
Mailing Address - Country:US
Mailing Address - Phone:706-814-1099
Mailing Address - Fax:
Practice Address - Street 1:1018 DRUID PARK AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-5848
Practice Address - Country:US
Practice Address - Phone:706-737-7371
Practice Address - Fax:706-737-7372
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4837225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4837OtherGEORGIA PHYSICAL THERAPY LICENSE NUMBER