Provider Demographics
NPI:1174914147
Name:BAGLEY, JAKE WOOD PUTNAM (DPT)
Entity type:Individual
Prefix:MR
First Name:JAKE
Middle Name:WOOD PUTNAM
Last Name:BAGLEY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2556 47TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94121-3206
Mailing Address - Country:US
Mailing Address - Phone:415-498-0537
Mailing Address - Fax:
Practice Address - Street 1:303 2ND ST STE 115C
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94107
Practice Address - Country:US
Practice Address - Phone:415-498-0537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-12
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0012518225100000X
CA292658225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist