Provider Demographics
NPI:1770789208
Name:BAGGETT, JONATHAN LOUIS (PTA)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:LOUIS
Last Name:BAGGETT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2190 ROCKY BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:SUMRALL
Mailing Address - State:MS
Mailing Address - Zip Code:39482-3666
Mailing Address - Country:US
Mailing Address - Phone:985-294-3756
Mailing Address - Fax:
Practice Address - Street 1:711 AVIGNON DR
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-5120
Practice Address - Country:US
Practice Address - Phone:601-605-6777
Practice Address - Fax:800-517-6935
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA4234225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant