Healthcare Provider Details

I. General information

NPI: 1902541485
Provider Name (Legal Business Name): JENNIFER W FAGBEMI EDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2022
Last Update Date: 04/29/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 RENAISSANCE DR NE APT 2A
CONYERS GA
30012-8026
US

IV. Provider business mailing address

1502 RENAISSANCE DR NE APT 2A
CONYERS GA
30012-8026
US

V. Phone/Fax

Practice location:
  • Phone: 404-247-5232
  • Fax: 470-321-5245
Mailing address:
  • Phone: 404-247-5232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number164478
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: