Provider Demographics
NPI:1871924407
Name:FAGAN, JENNIFER (MA 60367097)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FAGAN
Suffix:
Gender:F
Credentials:MA 60367097
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 BICKFORD AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98290-1771
Mailing Address - Country:US
Mailing Address - Phone:425-319-1123
Mailing Address - Fax:360-863-2649
Practice Address - Street 1:1800 BICKFORD AVE
Practice Address - Street 2:STE 201
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-1771
Practice Address - Country:US
Practice Address - Phone:425-319-1123
Practice Address - Fax:360-863-2649
Is Sole Proprietor?:No
Enumeration Date:2013-12-08
Last Update Date:2013-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60367097225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist