Healthcare Provider Details

I. General information

NPI: 1154955656
Provider Name (Legal Business Name): JESSICA ANNE FAGAN TLLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 06/03/2025
Certification Date: 05/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20300 SUPERIOR RD STE 250
TAYLOR MI
48180-6342
US

IV. Provider business mailing address

20300 SUPERIOR RD STE 200
TAYLOR MI
48180-6303
US

V. Phone/Fax

Practice location:
  • Phone: 734-785-7700
  • Fax:
Mailing address:
  • Phone: 734-785-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6362010152
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: