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General NPI Number Information
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NPI Number | 1245936434
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Entity Type | Individual
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Provider Name | JESSIE ELIZABETH BAGWELL
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Gender | Female
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Dates
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Enumeration Date | 01/31/2023
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Last Update Date | 01/31/2023
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Provider Practice Location Address
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Address Line | 3090 N ACADEMY BLVD
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City | COLORADO SPRINGS
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State | CO
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Zip | 80917-5368
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Country | US
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Telephone | 719-574-8300
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Fax | 719-574-9547
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Provider Business Mailing Address
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Address Line | 4350 STAR RANCH RD
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City | COLORADO SPRINGS
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State | CO
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Zip | 80906-7641
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Country | US
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Telephone | 530-470-3016
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | OT.0004341
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License Number State | CO
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