Provider Demographics
NPI:1720180441
Name:BAGLEY, JESSICA (MOTR/L)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:
Last Name:BAGLEY
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3841 E 38 N
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5708
Mailing Address - Country:US
Mailing Address - Phone:208-745-9373
Mailing Address - Fax:
Practice Address - Street 1:510 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6154
Practice Address - Country:US
Practice Address - Phone:208-589-9578
Practice Address - Fax:208-542-9577
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-779225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist