Healthcare Provider Details

I. General information

NPI: 1487872909
Provider Name (Legal Business Name): JENNIFER A. HAGERTY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2007
Last Update Date: 09/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 ROCKLAND ROAD
WILMINGTON DE
19803-3607
US

IV. Provider business mailing address

PO BOX 191 PROVIDER ENROLLMENT DEPT
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 302-651-4200
  • Fax: 302-651-6410
Mailing address:
  • Phone: 302-651-6212
  • Fax: 302-651-6212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036-113383
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberC20009386
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberOS010769L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: