Healthcare Provider Details

I. General information

NPI: 1376949792
Provider Name (Legal Business Name): JARED FAGANS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2014
Last Update Date: 11/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1361 ROUTE 72 W
MANAHAWKIN NJ
08050-2417
US

IV. Provider business mailing address

1361 ROUTE 72 W
MANAHAWKIN NJ
08050-2417
US

V. Phone/Fax

Practice location:
  • Phone: 201-213-9133
  • Fax:
Mailing address:
  • Phone: 201-213-9133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: