Provider Demographics
NPI:1184647505
Name:BAGEN, JENNY T (NP)
Entity Type:Individual
Prefix:MS
First Name:JENNY
Middle Name:T
Last Name:BAGEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 SHERIDAN DR
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1248
Mailing Address - Country:US
Mailing Address - Phone:716-432-2892
Mailing Address - Fax:716-389-4155
Practice Address - Street 1:1405 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14217-1248
Practice Address - Country:US
Practice Address - Phone:716-432-2892
Practice Address - Fax:716-389-4155
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2019-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400997363LP0808X
NYF400997-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02792363Medicaid