Provider Demographics
NPI:1093161473
Name:BAGBY, JESSICA (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:BAGBY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:BRICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1224 8TH ST
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350-1527
Practice Address - Country:US
Practice Address - Phone:208-436-0481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-16485207P00000X
CAA150392207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine