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General NPI Number Information
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NPI Number | 1588941082
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Entity Type | Individual
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Provider Name | JODIE JAN BAGLEY MA
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Gender | Female
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Dates
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Enumeration Date | 11/10/2011
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Last Update Date | 08/19/2014
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Provider Practice Location Address
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Address Line | 712 SE HAWTHORNE BLVD STE 100
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City | PORTLAND
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State | OR
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Zip | 97214-3538
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Country | US
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Telephone | 503-913-5733
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Fax | 503-327-8005
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Provider Business Mailing Address
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Address Line | 712 SE HAWTHORNE BLVD STE 100
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City | PORTLAND
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State | OR
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Zip | 97214-3538
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Country | US
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Telephone | 503-913-5733
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Fax | 503-327-8005
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | R-1935
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License Number State | OR
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