Provider Demographics
NPI:1144363151
Name:FAGAN, JENNIFER JOY (COTA)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:JOY
Last Name:FAGAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 WINCHESTER WAY
Mailing Address - Street 2:
Mailing Address - City:WASHINGTONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10992-1741
Mailing Address - Country:US
Mailing Address - Phone:845-496-1459
Mailing Address - Fax:
Practice Address - Street 1:1607 ROUTE 300 STE 102
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-1738
Practice Address - Country:US
Practice Address - Phone:845-564-9853
Practice Address - Fax:845-564-6974
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006651174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist