Provider Demographics
NPI:1609556273
Name:BAGLEY, JACOB (SOIDC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BAGLEY
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5185 COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-1126
Mailing Address - Country:US
Mailing Address - Phone:412-780-8250
Mailing Address - Fax:
Practice Address - Street 1:COURTHOUSE RD
Practice Address - Street 2:BUILDING A66
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547
Practice Address - Country:US
Practice Address - Phone:910-440-7925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman