Healthcare Provider Details

I. General information

NPI: 1689668162
Provider Name (Legal Business Name): JENNIFER MARY FAGEDES O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 E 7TH ST STE 400
CINCINNATI OH
45202-2476
US

IV. Provider business mailing address

35 E 7TH ST STE 400
CINCINNATI OH
45202-2476
US

V. Phone/Fax

Practice location:
  • Phone: 513-621-0979
  • Fax: 513-421-5345
Mailing address:
  • Phone: 513-621-0979
  • Fax: 513-421-5345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4098-T1093
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: