Provider Demographics
NPI:1588941082
Name:BAGLEY, JODIE JAN (MA)
Entity type:Individual
Prefix:
First Name:JODIE
Middle Name:JAN
Last Name:BAGLEY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:JODIE
Other - Middle Name:JAN
Other - Last Name:TINGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:712 SE HAWTHORNE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3538
Mailing Address - Country:US
Mailing Address - Phone:503-913-5733
Mailing Address - Fax:503-327-8005
Practice Address - Street 1:712 SE HAWTHORNE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3538
Practice Address - Country:US
Practice Address - Phone:503-913-5733
Practice Address - Fax:503-327-8005
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR-1935101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional