Basic Information
| Provider Information | |||||||||
| NPI: | 1255859690 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAGG | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10549 | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337330549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278248181 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1344 22ND ST S | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337122744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278248181 | ||||||||
| FaxNumber: | 7278248137 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2017 | ||||||||
| LastUpdateDate: | 11/10/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
No ID Information.