Healthcare Provider Details

I. General information

NPI: 1528549508
Provider Name (Legal Business Name): JESSICA FAGEN PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 E 55TH ST APT 3D
NEW YORK NY
10022-4050
US

IV. Provider business mailing address

28 HOYTS LN
BEDFORD CORNERS NY
10549-4856
US

V. Phone/Fax

Practice location:
  • Phone: 516-728-5246
  • Fax:
Mailing address:
  • Phone: 516-728-5246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number022717
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: