Provider Demographics
NPI:1821392804
Name:BAGANG, JASSELLE (PT)
Entity Type:Individual
Prefix:
First Name:JASSELLE
Middle Name:
Last Name:BAGANG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5909 BEVERLY DR E
Mailing Address - Street 2:2126
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76132-5808
Mailing Address - Country:US
Mailing Address - Phone:817-903-1920
Mailing Address - Fax:
Practice Address - Street 1:5909 BEVERLY DR E
Practice Address - Street 2:2126
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76132-5808
Practice Address - Country:US
Practice Address - Phone:817-903-1920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006745225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant