Provider Demographics
NPI:1942304209
Name:BAGGERMAN, MARY JEAN (MA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JEAN
Last Name:BAGGERMAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2585
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49081-2585
Mailing Address - Country:US
Mailing Address - Phone:269-381-0150
Mailing Address - Fax:269-373-4720
Practice Address - Street 1:8036 MOORSBRIDGE ROAD
Practice Address - Street 2:SUITE #2
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4417
Practice Address - Country:US
Practice Address - Phone:269-327-1438
Practice Address - Fax:269-327-6454
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401002019103TC1900X
MI68010345041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OTH000Medicare UPIN