Provider Demographics
NPI:1386420503
Name:BAGAZA, JEAN B
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:B
Last Name:BAGAZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 CARROWMOORE DR
Mailing Address - Street 2:
Mailing Address - City:PICKERINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43147-3511
Mailing Address - Country:US
Mailing Address - Phone:515-380-5393
Mailing Address - Fax:
Practice Address - Street 1:242 CARROWMOORE DR
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-3511
Practice Address - Country:US
Practice Address - Phone:515-380-5393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-04
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH103TB0200X, 103TM1800X
103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral