Provider Demographics
NPI:1245936434
Name:BAGWELL, JESSIE ELIZABETH
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:ELIZABETH
Last Name:BAGWELL
Suffix:
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 1:4350 STAR RANCH RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-7641
Mailing Address - Country:US
Mailing Address - Phone:530-470-3016
Mailing Address - Fax:
Practice Address - Street 1:3090 N ACADEMY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5368
Practice Address - Country:US
Practice Address - Phone:719-574-8300
Practice Address - Fax:719-574-9547
Is Sole Proprietor?:No
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0004341225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist