Provider Demographics
NPI:1902541485
Name:FAGBEMI, JENNIFER W (EDS)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:W
Last Name:FAGBEMI
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 RENAISSANCE DR NE APT 2A
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-8026
Mailing Address - Country:US
Mailing Address - Phone:404-247-5232
Mailing Address - Fax:
Practice Address - Street 1:1502 RENAISSANCE DR NE APT 2A
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-8026
Practice Address - Country:US
Practice Address - Phone:404-247-5232
Practice Address - Fax:470-321-5245
Is Sole Proprietor?:No
Enumeration Date:2022-04-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA164478103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool