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General NPI Number Information
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NPI Number | 1821392804
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Entity Type | Individual
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Provider Name | JASSELLE BAGANG PT
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Gender | Female
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Dates
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Enumeration Date | 01/05/2011
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Last Update Date | 01/05/2011
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Provider Practice Location Address
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Address Line | 5909 BEVERLY DR E 2126
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City | BENBROOK
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State | TX
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Zip | 76132-5808
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Country | US
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Telephone | 817-903-1920
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Fax |
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Provider Business Mailing Address
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Address Line | 5909 BEVERLY DR E 2126
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City | BENBROOK
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State | TX
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Zip | 76132-5808
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Country | US
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Telephone | 817-903-1920
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 006745
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License Number State | NY
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