Provider Demographics
NPI:1235898008
Name:BAGNELL, JENNIFER LEIGH I
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEIGH
Last Name:BAGNELL
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 WARDELL AVE
Mailing Address - Street 2:
Mailing Address - City:RUMSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07760-1036
Mailing Address - Country:US
Mailing Address - Phone:732-865-6117
Mailing Address - Fax:
Practice Address - Street 1:51 WARDELL AVE
Practice Address - Street 2:
Practice Address - City:RUMSON
Practice Address - State:NJ
Practice Address - Zip Code:07760-1036
Practice Address - Country:US
Practice Address - Phone:732-865-6117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1650442363A00000X
NJ25MP00666400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant